Location
Suwanee, GA
Start Date
7-5-2024 1:00 PM
End Date
7-5-2024 4:00 PM
Description
Background:
Thoracic outlet syndrome is largely overlooked in the pediatric population due to its widely varied presentation and not being commonly viewed as a pediatric disorder. This case study will demonstrate an adolescent with recurrent DVTs who was found to have venous thoracic outlet syndrome caused by anatomic compression and an underlying hypercoagulable disorder. The aim of this report is to highlight the presentation of venous TOS in a pediatric patient without a clear anatomic cause or Paget Schroetter syndrome.
Case Presentation:
A 17-year-old Caucasian male with no PMHx presented to the Pediatric ED with 1 day of sudden onset right arm redness and swelling associated with pain that worsened throughout the day. He is a soccer player with his last game being 2 days ago with no recent injuries or traumas. On a physical exam, he was noted to have erythema and edema throughout the right upper extremity as well as a delayed capillary refill in the RUE. A doppler revealed thrombosis of the right mid subclavian and axillary veins. With a mechanical thrombectomy scheduled, an investigation into the cause of this DVT was performed. A CXR and plain films of the C-spine were ordered which ruled out the most common cause of thoracic outlet syndrome, a cervical rib or extension of C7 transverse process. Paget Schloetter syndrome, also known as effort syndrome, was also thought to be unlikely as this patient is left-handed, does not play an over-the-head sport, and denied excessive use of the upper extremity. An autoimmune workup revealed that the patient had a heterozygous factor V Leiden mutation.
The patient was admitted and over the course of his hospitalization he had multiple recurrences of DVT in the same location despite anticoagulation in a therapeutic range and minimal movement of the affected arm. A provocative venogram performed by IR found that with hyperabduction of the right arm, a complete obstruction of central venous outflow of the subclavian vein occurred due to the patient’s anatomy with brisk resolution of flow when the arm was returned. The rapid recurrence of thrombus and venogram findings confirmed a diagnosis of venous thoracic outlet obstruction. Overnight, there was a recurrence of symptoms but without signs of neurovascular compromise. Given these findings it was decided to keep the patient on a high-dose heparin drop with a therapeutic range between 0.5-0.7 and transfer the patient to a local Pediatric hospital for a right robotic-assisted first-rib resection and scalenectomy (FRRS).
Discussion:
With the combination of an anatomic compressive etiology and underlying hypercoagulable disorder, this case illustrates a unique presentation of DVT in a young healthy person in the upper extremity. It is important to understand pediatric DVT cases and the risks if they are not recognized or continue to recur. Early identification and treatment for this patient with venous thoracic outlet syndrome will hopefully allow him to return to his regular activities without further complications.
Embargo Period
6-27-2024
Included in
A “CLOT”-astrophe: Recurrent DVTs in a Pediatric Patient
Suwanee, GA
Background:
Thoracic outlet syndrome is largely overlooked in the pediatric population due to its widely varied presentation and not being commonly viewed as a pediatric disorder. This case study will demonstrate an adolescent with recurrent DVTs who was found to have venous thoracic outlet syndrome caused by anatomic compression and an underlying hypercoagulable disorder. The aim of this report is to highlight the presentation of venous TOS in a pediatric patient without a clear anatomic cause or Paget Schroetter syndrome.
Case Presentation:
A 17-year-old Caucasian male with no PMHx presented to the Pediatric ED with 1 day of sudden onset right arm redness and swelling associated with pain that worsened throughout the day. He is a soccer player with his last game being 2 days ago with no recent injuries or traumas. On a physical exam, he was noted to have erythema and edema throughout the right upper extremity as well as a delayed capillary refill in the RUE. A doppler revealed thrombosis of the right mid subclavian and axillary veins. With a mechanical thrombectomy scheduled, an investigation into the cause of this DVT was performed. A CXR and plain films of the C-spine were ordered which ruled out the most common cause of thoracic outlet syndrome, a cervical rib or extension of C7 transverse process. Paget Schloetter syndrome, also known as effort syndrome, was also thought to be unlikely as this patient is left-handed, does not play an over-the-head sport, and denied excessive use of the upper extremity. An autoimmune workup revealed that the patient had a heterozygous factor V Leiden mutation.
The patient was admitted and over the course of his hospitalization he had multiple recurrences of DVT in the same location despite anticoagulation in a therapeutic range and minimal movement of the affected arm. A provocative venogram performed by IR found that with hyperabduction of the right arm, a complete obstruction of central venous outflow of the subclavian vein occurred due to the patient’s anatomy with brisk resolution of flow when the arm was returned. The rapid recurrence of thrombus and venogram findings confirmed a diagnosis of venous thoracic outlet obstruction. Overnight, there was a recurrence of symptoms but without signs of neurovascular compromise. Given these findings it was decided to keep the patient on a high-dose heparin drop with a therapeutic range between 0.5-0.7 and transfer the patient to a local Pediatric hospital for a right robotic-assisted first-rib resection and scalenectomy (FRRS).
Discussion:
With the combination of an anatomic compressive etiology and underlying hypercoagulable disorder, this case illustrates a unique presentation of DVT in a young healthy person in the upper extremity. It is important to understand pediatric DVT cases and the risks if they are not recognized or continue to recur. Early identification and treatment for this patient with venous thoracic outlet syndrome will hopefully allow him to return to his regular activities without further complications.