Venous thoracic outlet syndrome with acute thrombosis of the subclavian vein (Paget-Schroetter syndrome)

Introduction Acute thrombotic occlusion of the subclavian or axillary vein is referred to as Paget-Schroetter syndrome (PSS) in the literature. It results from microtrauma or intimal tears of the vein and presents clinically with venous swelling, prominence of the upper arm veins in addition to infraclavicular or axillary pressure pain. Chronic pathological changes of the axillary and subclavian veins due to anatomical changes in the upper thoracic aperture are referred to as venous thoracic outlet syndrome (TOS). Aim The aim of this scientific case report is to investigate the rare case of a PSS with the individual case-specific clinical symptom severity based on relevant references from the scientific medical literature and the experience gained in diagnostic and therapeutic case management, including the outcome and a prognostic evaluation. Case report A 30-year-old hobby athlete complained of swelling and pressure pain in the right arm that had suddenly appeared the day before, with a slight bluish-livid discoloration of the skin. Duplex ultrasonography, CT and MR angiography in addition to venography revealed thrombosis of the right subclavian vein up to the superior vena cava in thoracic outlet syndrome. Owing to the acute event and severe symptoms, an indication for drug-induced intravenous thrombolysis with Actilyse (R) (Alteplase; Boehringer Ingelheim, Ingelheim/Rhein, Germany) was seen, which was locally applied via a catheter through the brachial vein. Residual thrombi in the subclavian vein were detected along with an obstruction to the subclavian vein, which was dilated using an image-guided balloon. Anticoagulation was initiated with Xarelto (R) 20 & x202f;mg daily (Rivaroxaban; Bayer, Leverkusen, Germany). Control investigation after 3 months revealed significantly reduced symptomatology. The conservative therapy will be continued, with reduction of sports activities and additional rivaroxaban for at least 6 months. The possible cause was determined: strenuous and repeated activity of the upper extremities due to sports exercise. Conlusion PSS is a very rare disease. It can be treated conservatively, interventionally and by surgery. In acute severe thrombosis, fibrinolysis should be performed with plasminogen activators. In severe cases and in recurrences, the concrete cause of the compression should be corrected surgically if possible.