Location
Philadelphia, PA
Start Date
17-4-2026 1:30 PM
End Date
17-4-2026 2:30 PM
Description
Introduction
Paget-Schroetter Syndrome is an occlusive thoracic outlet syndrome of the upper extremity affecting the axillary and subclavian vasculature most common in young adult men to middle aged men. Paget-Schroetter was first described in the late 1800s in reviews of young adults with repetitive arm use. Continuous overhead physical activity, cervical ribs, abnormal rib tubercles, and scalene impingement are common causes leading to repeated vessel injury and thrombosis affecting 1 in 100,000. The purpose of this exhibit is to gain an understanding of the pathophysiological mechanisms leading to Paget-Schroetter Syndrome and the clinical interventions available to patients with an emphasis on treatment provided by interventional radiologists including diagnostic imaging features.
Methods
This study synthesizes current literature regarding diagnostic imaging, intervention, and outcomes for Paget-Schroetter Syndrome and differentiating Paget-Schroetter from other thoracic outlet syndromes (TOS).
Results
Compression of the brachial plexus is the most common form of TOS followed by arterial and venous TOS. Pathophysiologically, repetitive occlusion of the axillary or subclavian vein leads to microvascular trauma and subsequent fibrosis predisposing to venous thrombosis and occlusive crisis. The development of thrombosis leads to venous congestion with prominent collaterals and pulmonary embolism in 10% of cases. Symptomatology aligns with venous thrombosis syndromes: swelling, pain, warmth, and palpable cord or heaviness of the upper extremity, compared to the Five P’s of arterial occlusion (pain, pallor, pulselessness, paresthesia, and paralysis) and paresthesia following nerve distributions in neurological TOS. Diagnostically, PSS is confirmed via ultrasound, CT/MRI with contrast, and or venogram. Management of Paget-Schroetter Syndrome is initially approached with catheter-directed tPA and anticoagulation for non limb threatened patients, respectively. Secondarily, interventional radiologists may perform mechanical thrombectomy and subsequent balloon angioplasty with or without stenting. Thrombectomy is commonly aspiration thrombectomy. The gold standard therapy following diagnosis and acute presentation treatment is first rib resection and anterior scalenectomy with vascular surgery. In patients with treatment resistant disease and older patients, stenting may be explored but not preferred for first line treatment as stent patency decreases over time and repeat interventions may be required to recanalize or dilate. Treatment goals of PSS is long term patency of the upper extremity vasculature and reduction in venous collaterals visualized on clinical examination and imaging in addition to reduction in clinical symptomology.
Conclusion
Paget-Schroetter Syndrome management has evolved in recent decades with the advent of intravascular mechanical thrombectomy and balloon angioplasty in combination with standard of care consisting of first rib resection and anterior scalenectomy. Minimally invasive fluoroscopic guided interventions will continue to support patients with PSS diagnostically and therapeutically as a primary or supportive modality.
Embargo Period
6-3-2026
Included in
An Interventional Radiologist’s Approach to Paget-Schroetter Syndrome and Clinical Intervention Overview
Philadelphia, PA
Introduction
Paget-Schroetter Syndrome is an occlusive thoracic outlet syndrome of the upper extremity affecting the axillary and subclavian vasculature most common in young adult men to middle aged men. Paget-Schroetter was first described in the late 1800s in reviews of young adults with repetitive arm use. Continuous overhead physical activity, cervical ribs, abnormal rib tubercles, and scalene impingement are common causes leading to repeated vessel injury and thrombosis affecting 1 in 100,000. The purpose of this exhibit is to gain an understanding of the pathophysiological mechanisms leading to Paget-Schroetter Syndrome and the clinical interventions available to patients with an emphasis on treatment provided by interventional radiologists including diagnostic imaging features.
Methods
This study synthesizes current literature regarding diagnostic imaging, intervention, and outcomes for Paget-Schroetter Syndrome and differentiating Paget-Schroetter from other thoracic outlet syndromes (TOS).
Results
Compression of the brachial plexus is the most common form of TOS followed by arterial and venous TOS. Pathophysiologically, repetitive occlusion of the axillary or subclavian vein leads to microvascular trauma and subsequent fibrosis predisposing to venous thrombosis and occlusive crisis. The development of thrombosis leads to venous congestion with prominent collaterals and pulmonary embolism in 10% of cases. Symptomatology aligns with venous thrombosis syndromes: swelling, pain, warmth, and palpable cord or heaviness of the upper extremity, compared to the Five P’s of arterial occlusion (pain, pallor, pulselessness, paresthesia, and paralysis) and paresthesia following nerve distributions in neurological TOS. Diagnostically, PSS is confirmed via ultrasound, CT/MRI with contrast, and or venogram. Management of Paget-Schroetter Syndrome is initially approached with catheter-directed tPA and anticoagulation for non limb threatened patients, respectively. Secondarily, interventional radiologists may perform mechanical thrombectomy and subsequent balloon angioplasty with or without stenting. Thrombectomy is commonly aspiration thrombectomy. The gold standard therapy following diagnosis and acute presentation treatment is first rib resection and anterior scalenectomy with vascular surgery. In patients with treatment resistant disease and older patients, stenting may be explored but not preferred for first line treatment as stent patency decreases over time and repeat interventions may be required to recanalize or dilate. Treatment goals of PSS is long term patency of the upper extremity vasculature and reduction in venous collaterals visualized on clinical examination and imaging in addition to reduction in clinical symptomology.
Conclusion
Paget-Schroetter Syndrome management has evolved in recent decades with the advent of intravascular mechanical thrombectomy and balloon angioplasty in combination with standard of care consisting of first rib resection and anterior scalenectomy. Minimally invasive fluoroscopic guided interventions will continue to support patients with PSS diagnostically and therapeutically as a primary or supportive modality.