Paget-Schroetter syndrome: diagnostic limitations of imaging upper extremity deep vein thrombosis

Paget-Schroetter syndrome is a rare but potentially debilitating condition affecting young, otherwise healthy individuals. This condition, also known as effort thrombosis, is an upper extremity deep vein thrombosis classically caused by anatomical abnormalities compressing the neurovascular structures of the thoracic outlet. The diagnosis is important to emergency medicine providers due to its secondary morbidity and mortality. Common complications affecting these active adults are pulmonary embolism and postthrombotic syndrome. Most patients report a precedent history of vigorous exercise or activity involving the upper extremities. We present a case of a 23-year-old man with redness and swelling of his dominant arm after weightlifting. Previous literature describes Paget-Schroetter syndrome from repetitive activities. The report highlights the limitations of imaging studies in proximal upper extremity deep vein thromboses. The initial selected imaging study, Doppler ultrasound, was negative in our case and was followed by a nondiagnostic computed tomographic venogram. Although ultrasound is the preferred diagnostic imaging modality, it is limited when thrombosis is present in the noncompressible region of the clavicle. Magnetic resonance venogram or computed tomographic venogram is recommended if index of suspicion is high and the ultrasound shows normal results, but these studies are highly dependent on technique, flow, and timing. The eventual diagnosis of axillosubclavian thrombosis was obtained only after specialty consultation and formal venography. This case discusses the limitations of each imaging modality and the importance of a comprehensive clinical approach to this rare diagnosis.