A 22-year-old competitive swimmer develops sudden swelling and heaviness of his right arm after intensive training. There is dilated superficial veining over the shoulder and the whole limb is oedematous. Duplex ultrasound confirms thrombosis of the axillary-subclavian vein. After initial anticoagulation, what is the definitive management?

• A Six months of warfarin alone, no further intervention
• B Catheter-directed thrombolysis followed by first rib resection ✓
• C Permanent inferior vena cava filter placement
• D Subclavian vein angioplasty with stenting as first-line therapy

Explanation

This is Paget-Schroetter disease, effort thrombosis of the subclavian-axillary vein caused by compression at the costoclavicular space, the venous form of thoracic outlet syndrome seen in young athletes. Standard management is catheter-directed thrombolysis in the acute setting, anticoagulation, and decompression by resection of the first rib to remove the compressive anatomical cause. Venous stenting alone fails because the extrinsic compression fractures or reoccludes the stent.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.