Paget-Schroetter Syndrome: Persistent Upper Extremity Swelling After Thrombolysis

A 55-year-old male dentist presented with persistent right upper extremity swelling twenty-four hours after catheter-directed thrombolysis, mechanical thrombectomy, and balloon angioplasty for an acute deep vein thrombosis of the right subclavian, axillary, and brachial veins. Symptoms had originated after overhead weightlifting, and the patient reported a two-year history of thoracic outlet–type symptoms previously managed with home physical therapy. Failure of swelling to resolve after thrombolysis prompted urgent vascular surgery referral. Repeat venous duplex demonstrated acute-on-chronic thrombosis throughout the right upper extremity deep venous system. Repeat mechanical thrombectomy and angioplasty were performed, with intraoperative findings of complete external compression of the subclavian vein by the first rib at the venous thoracic outlet. The patient was scheduled for first rib resection and scalenectomy. This case illustrates the classic presentation of Paget–Schroetter syndrome, or effort-induced subclavian vein thrombosis, and emphasizes that anticoagulation and thrombolysis alone are insufficient without thoracic outlet decompression to prevent recurrence and post-thrombotic syndrome.