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Usa jobs government jobs login paget schroetter dvt. Paget-Schroetter Syndrome in a Young Female

 
Recent medical history included a diagnosis of deep vein thrombosis (DVT) in the He worked strenuous jobs in the construction industry most of his life. Paget–Schroeder syndrome is a very rare disease that causes vascular endothelial dysfunction from the retraction of the veins passing the thoracic outlet due to. The hippocampus (HIPP) is essential for memory formation and is involved in early stages of disease. In fact, hippocampal atrophy is used as an early biomarker.

 
 

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Just before his final follow-up 2 months post-FRR with intraoperative PTA , the patient complained of mild, intermittent arm swelling associated with pain that coincided with an increase in upper extremity activity. Venography was devoid of thrombus, but showed restenosis unresponsive to serial PTA; therefore, a mm self-expanding bare metal stent was deployed across the stenotic region with restoration of flow Fig.

He was continued on oral anticoagulation for an additional 2. At his 6-month follow-up, right upper extremity duplex ultrasound was negative for thrombus or wall thickening in the venous system, therefore warfarin was discontinued and he was transitioned to oral antiplatelet therapy aspirin 81 mg daily for 3 months. Upper extremity deep vein thrombosis is an uncommon entity; although most of the thrombotic events occurring at this site are secondary to catheters, indwelling devices, and cancer, venous thoracic outlet syndrome VTOS is an important cause of primary thrombosis.

VTOS is caused by extrinsic compression of the subclavian vein between the anterior scalene muscle and the junction of the first rib, clavicle, and subclavius muscle.

Delayed presentation is common as distal tributaries form in response to venous congestion from luminal compression and initial thrombus; acute symptoms are hypothesized to occur after propagation of the clot obstructs these distal collaterals. This condition is often misdiagnosed or underdiagnosed; prompt recognition and treatment within 14 days of the acute thrombus is one of the most important predictors of outcome. Treatment algorithms are highly varied given the relative rarity of this disease and lack of quality-randomized controlled studies.

Most protocols are guided by single institutional reports, retrospective reviews, and expert opinion. One of the most commonly used operative algorithms was developed by Kunkel and Machleder in the s; this protocol included early thrombolysis and 3 months of anticoagulation before transaxillary FRR.

Conservative, selective surgical algorithms have been described. For example, Lee et al from Stanford University performed rib resection only on those patients that had recurrent or persistent symptoms, had ultrasound evidence of wall thickening, or had rethrombosis after the initial clot lysis. Furthermore, this need for FRR increased with younger age, a defining characteristic of the active duty population. Not only are there disparities between surgical and nonsurgical algorithms as discussed above, but there is also a lack of consensus on the appropriate timing of FRR, PTA, and stenting.

Repeat venography was obtained at approximately 10 days postoperatively; if residual stenosis was present and not responsive to PTA, stenting was performed. Standard postintervention oral anticoagulation duration was for 3 months. This one-stage operation was hypothesized to decrease the risk of rethrombosis and need for stent placement in the postoperative period.

The results of the venogram dictated additional management anticoagulation plus PTA or anticoagulation alone. Other literature suggest that PTA may be used before or after surgical decompression, whereas stent placement is typically reserved for residual stenosis, not responsive to PTA, only after the extrinsic compression has been removed.

Reviewing literature for other military case reports, FRR was delayed 8 months after presentation, 17 there was no mention of time course to FRR, 18 , 19 or patients received conservative, nonsurgical management only. Presurgical intervention beyond thrombolysis providing immediate symptom relief in the acute phase may have little impact on the long-term patency and recovery as long as FRR is performed promptly.

Therefore, we could have considered thrombolysis alone followed by FRR during the initial hospitalization to reduce his total course of treatment. Predecompression PTA may be a superfluous attempt as the extrinsic forces on the vein have not been removed. More importantly, it may be difficult to ascertain the final disposition of the treated vein following surgery as this area can be challenging to duplex and the patient may not be active enough to induce symptoms of venous obstruction related to residual intrinsic defects.

Reported symptomatology and physical examination alone have been shown to be an inaccurate means of determining venous patency. Therefore, accurate and early postoperative imaging is key; routine venography, as described by the Johns Hopkins series, has been justified in the absence of symptoms and has been proclaimed as best practice for long-term success. Although, we did perform a routine ultrasound at his 6-month follow-up to support discontinuation of oral anticoagulation, we should additionally consider a routine ultrasound at the month mark.

Diagnosis and treatment of VTOS is a clinical challenge. Primary care providers in the Fleet must maintain a high index of suspicion when a patient presents with upper extremity complaints related to recent vigorous exercise. To avoid long-term disability in this unique patient population, recognition and prompt referral for specialized surgical intervention is paramount. Immediate or early decompression with FRR should be considered as this has shown to reduce the risk of pulmonary embolism, rethrombosis, and the debilitating sequelae of post-thrombotic syndrome.

Routine ultrasound examination should be performed in the asymptomatic patient up to 12 months postsurgery. VG Katana and JS Weiss had full access to all the data in the study and take responsibility for the integrity of the data, and VG Katana and JS Weiss interpreted the data and take responsibility for the accuracy of the data analysis.

Drafting of the manuscript and critical revision of the manuscript for important intellectual content was performed by VG Katana and JS Weiss.

Phlebology ; 30 10 : — Google Scholar. Curr Opin Cardiol ; 25 6 : — Vasc Med ; 20 2 : — 9. Curr Treat Options Cardiovasc Med ; 4 3 : — Acute Paget-Schroetter syndrome: does the first rib routinely need to be removed after thrombolysis? Ann Vasc Surg ; 29 6 : — 7. A staged, multidisciplinary approach. Arch Surg ; 10 : — 8. J Invasive Cardiol ; 27 9 : — 8. J Vasc Surg ; 43 6 : — J Vasc Surg ; 60 4 : — 7. Blood flow restriction provides tremendous opportunity with a potential for accelerated exercise rehabilitation and injury prevention.

This modality could be used in the military setting to help injured active duty personnel expeditiously return to deployable status. Further prospective randomized controlled trials are warranted to further support BFRT safety; however, from this literature review, it can be concluded that BFRT can be utilized safely in the proper patient population when administered by qualified professionals who have undergone the appropriate training.

Blood flow restriction therapy BFRT is a tool used in many scenarios, ranging from muscle building in athletic performance to decreasing recovery time in postoperative orthopedic rehabilitation. The efficacy of BFRT for treating diseases has been increasingly researched in recent years; however, there has been less literature specifically aimed at establishing the safety of this relatively novel therapy.

The terms BFRT and KAATSU are often used interchangeably depending on geographic location, with the main principle of both being a partial occlusion of arterial inflow and complete obstruction of venous outflow from the muscle.

The most common method to achieve this targeted occlusion is through application of a pneumatic cuff to the extremity of interest. This, in combination with low-resistance exercise training, provides many metabolic, hormonal, cardiovascular, and cellular advantages to the exercising muscle. The target range for papers to be included was from January to July To objectively categorize the adverse events, the authors modified an already validated scoring method for characterizing complications.

The Clavien—Dindo classification system, originally used to quantitatively rank postoperative complications, was modified in order to classify complications related to the non-surgical intervention, BFRT. Ten case reports, five case series, two national surveys, two questionnaires, six randomized controlled studies, and one systematic review were included in this literature review.

Of the studies from which exact results could be extracted, a total of 1, individuals reported an adverse event following BFRT use out of 25, people. Table I demonstrates the proportions of Grades from the modified Clavien—Dindo classification. The most commonly reported adverse events were numbness, dizziness, subcutaneous hemorrhage, and rhabdomyolysis.

There were unique adverse effects of this therapy reported in individuals with comorbid conditions, such as hypertension and thoracic outlet syndrome, which included isolated cases of central retinal vein occlusion CRVO and Paget—Schroeder syndrome PSS.

Studies that did not report the specific number of individuals reporting adverse outcomes were excluded from this table. There are 10 case reports that document adverse side effects with BFRT training. To highlight a few, the first reported case of rhabdomyolysis as it pertained to the concurrent use of BFRT was seen in In another case report, a year-old obese Japanese male performed BFRT on the first day of training and subsequently developed rhabdomyolysis.

There was no information regarding exercise intensity or occlusion pressure. Previous reports have shown PSS to be caused by weight-bearing exercises or push-ups. A case series including 21 healthy young adults reported minor side effects in three of the participants. One male experienced a brief syncope, while two others experienced pre-syncopal symptoms.

Parameters that included pain, lactate levels, hemodynamic changes, and D-dimer assessment were monitored, with no DVT formation occurring and no differences seen. Finally, a study looking at 20 intensive care unit patients who were in a coma saw no adverse effects when blood flow restriction was applied to a lower extremity limb and passive motion was completed. Although sparse, surveys provided the largest number of results reported for BFRT usage.

Notable complications included 1, people with subcutaneous hemorrhage, seven people with venous thrombus, one person with pulmonary embolism, one person with cerebral infarction, and one with rhabdomyolysis. In , Yasuda et al. Compared to the survey, no serious side effects such as rhabdomyolysis, pulmonary embolism, cerebral hemorrhage, or paralysis were reported. Minor side effects included cool feeling, numbness, subcutaneous hemorrhage, drowsiness, pain, nausea, itch, hypertension, anemia, headache, and others in a cohort amount that was not able to be determined.

There were two questionnaire studies that did not report specific patient numbers and thus were not included in the statistical analysis but are mentioned as follows. In one study, Brazilian physical rehabilitation and sports science professionals were surveyed and asked to report on side effects with the use of BFRT in their patients. A pilot randomized control study where BFRT was utilized in six patients with distal radius fractures treated with closed reduction and cast immobilization demonstrated that an 8-week course of BFRT was tolerated well with no complications.

Of the 10 patients who completed the trial using BFRT, none reported adverse events. A prospective randomized control trial analyzing limb circumference and strength of the upper extremity with and without BFRT after a 6-week low weight training program reported no adverse events in the 14 people who had BFRT applied.

One systematic review reporting on BFRT use for lower extremity weakness due to knee pathology from to showed no complications in individuals sequestered from the search. This study was developed to assess the frequency of adverse events associated with BFRT training reported in the literature.

Based on the Clavien—Dindo classification system, Within this study, there was variability in the setting in which KAATSU training was performed, in the type of exercises used, and in which limb was used for partial occlusion. In studies with more controlled settings and patient selection, no adverse events were noted.

In addition to increases in strength, 12 , 13 , 26 , 30 muscle hypertrophy, 27 , 30 and improved rehabilitation of musculoskeletal injury, 28 , 29 BFRT has been seen to reduce muscle wasting in elderly patients admitted to the intensive care unit, 21 and have systemic effects such as when implemented in pulmonary rehabilitation programs.

In turn, cardiac output is increased to meet demand of the exercising muscle. Ultimately, this increases blood pressure, which if already elevated in hypertensive individuals, could have detrimental effects. Sympathetic activity has a heightened baseline in people with cardiovascular disease such as hypertension and heart failure. Pope et al. The muscle hypertrophy obtained after BFRT is thought to result from the lactic acidosis that occurs with the combination of blood flow restriction and low-intensity repetitions.

This localized metabolic effect, along with systemic and hormonal actions, are not seen with BFRT used during no exercise or with walking. Another theorized risk of BFRT is its use in people with pre-existing diseases that affect the muscle itself.

However, it has been shown that BFRT usage in this patient population can be administered safely with positive impacts on multiple health parameters, including increased muscle strength and quality of life. A key component in the safety of this modality lies within the experience of the user or trainer, as well as adherence to established guidelines and protocols.

Patterson et al. One set pressure, or absolute pressure, should be watched carefully because the wide range of limb girth and cuff dimensions impacts this parameter. Although no absolute contraindications have been established for BFRT as it is a relatively new treatment modality, there have been plausible contraindications noted. Potential increases in adverse outcomes can be associated with hematologic diseases such as sickle cell anemia, Factor V Leiden, estrogen use, past events with venous thromboembolism, liver disease, or any other entity that increases the risk for blood clotting.

Lastly, any event that decreases blood movement, such as extended immobility or in the immediate postoperative period, can increase the risk for thromboembolism. Literature reviews are subject to the limitations of the given literature, and this review is no different. A primary limitation encountered in this study is the variability across the spectrum of BFRT protocols used in each study.

There was variability in the set cuff pressures, duration of use, and frequency. Additionally, there was little transparency in regard to how often these protocols are routinely followed and how often deviations occur when protocols were used.

Thrombolysis and heparin drip resumed after the venogram and continued for 3 days with a repeat venogram every day. She had multiple rechecks and venograms by vascular surgery. Overall, clot burden is much improved 3 days after thrombolysis, as shown in Figure 2 , but there is occlusion of the vein at the pinch point between the clavicle and first rib.

She continued on low-dose heparin for 3 more days, and thrombolytics were stopped. As there is increased risk for recurrence of clot until the first rib resection is done, a decision was made to perform open surgical decompression of the axillary subclavian vein via resection of first rib subclavian muscle resection, partial anterior scalenectomy, and venolysis.

Subsequently, she was discharged on Eliquis. Deep venous thrombosis primarily develops in the lower extremity venous system and less commonly in the upper extremities. However, with the increased use of central venous catheters, pacemakers, defibrillators incidence of upper extremity DVT has been increased. Upper extremity thrombosis predominantly involves brachial, axillary, and subclavian veins, less commonly in internal jugular veins, radial, and ulnar veins.

It occurs most frequently in the dominant arm of young athletes. Secondary thrombosis is substantially caused by catheters, including dialysis catheters, Port-A-Cath, PICC line, central venous catheters, pacemakers, or automated implantable cardioverter-defibrillator, followed by malignancies and less commonly by surgery, trauma to arm, and shoulder, pregnancy, and hormonal therapy. Main causes of thoracic outlet obstruction include congenital bony and muscular anomalies such as cervical ribs, abnormal scalene muscle attachment, and cervical fibro cartilaginous bands; acquired causes include trauma and scalene muscle hypertrophy from repeated upper extremity activities.

Since the subclavian vein passes through costoclavicular space at the anterior part of the first rib and clavicular junction, it is more susceptible to external compression from repetitive movements of the arm and shoulder due to overhead activities and exercises. Intima is more vulnerable to repetitive microtrauma leading to proliferation, fibrosis, and hyperplasia of the vein wall, which subsequently triggers a coagulation cascade resulting in thrombosis.

Paget-Schroetter syndrome presents with sudden onset of severe arm swelling, heaviness, and pain. Other symptoms include discoloration, paresthesias, and weakness in the arms. In severe cases with superior vena cava syndrome, collaterals can be seen on the arms and chest. Given that compression ultrasonography is widely available, cost-effective, and less invasive, it is more commonly used than CT and MR venography. If compression ultrasonography is inconclusive or equivocal, CT or MR venography can be used for high clinical suspicion cases.

Complications from venous thrombosis include pulmonary embolism, post-thrombotic syndrome, and recurrence of thrombosis. Nevertheless, these complications are less common in upper extremity DVT compared with lower extremity thrombosis. The incidence of pulmonary embolism PE in upper extremity thrombosis is 5. Post-thrombotic syndrome is a chronic debilitating and disabling complication of DVT of extremities, reducing the quality of life, especially when the dominant limb is involved.

It mainly presents with chronic pain, swelling, varicose veins, and, in severe cases, with ulcers. It is less common in the upper extremity compared with the lower extremity. The risk of developing post-thrombotic syndrome primary and secondary together and recurrent thromboembolism in upper extremity DVT is In the early s, treatment involved arm elevation, rest, and anticoagulation. Ten years later, thrombolysis was included in the treatment plan since there was an increased recurrence of thrombosis with anticoagulation alone.

Thrombolysis relieves symptoms by decreasing the clot burden. As effort thrombosis involves external compression of the axillary subclavian vein from bony abnormality at thoracic outlet, underlying mechanical obstruction needs to be relieved with surgical intervention. Prevention of long-term morbidity with recurrence of thrombosis, symptom relief, and overall outcomes are better achieved with first rib resection after thrombolysis.

Functional outcomes, including an early return to the activities and work, are better with thrombolysis with early surgical intervention groups. In Paget-Schroetter syndrome, the duration of symptoms plays a crucial role in the treatment. Thrombolysis is more likely to be successful in patients whose symptoms started in less than 14 days.

There is no statistically significant difference in the symptom resolution in the groups with first rib resection in less or more than 6 weeks. More studies are required on the duration of anticoagulation in these patients.

Internist, primary care physicians, and emergency room physicians can easily miss Paget-Schroetter syndrome. Increased awareness about the disease and timely referral to vascular surgeons is of paramount importance among physicians to prevent complications and worst outcomes with a delay of care.

Prompt diagnosis and early initiation of treatment are imperative for better results. Since the management of effort thrombosis differs from the regular DVT, physicians need to be familiar with treatment options, including thrombolysis and surgical intervention. A multidisciplinary team approach with an internist, vascular surgeon, and hematologist is required to manage the Paget-Schroetter syndrome as it includes both medical and surgical options.

Randomized controlled studies are needed to evaluate the efficacy of thrombolysis and surgical options. Author Contributions: VS conducted the chart review.

VS drafted the manuscript.

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