Sanson H, Gautier V, Stansal A, Sfeir D, Franceschi C, Priollet P
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
J Mal Vasc. 2016 Dec;41(6):396-402. doi: 10.1016/j.jmv.2016.10.004. Epub 2016 Nov 4.
Exercise-induced thrombosis is a rare cause of deep venous thrombosis (DVT) of the upper limb and usually affects young subjects without comorbid conditions. The diagnosis may be challenging.
A 23-year-old female right-handed French teacher and amateur violin player presented with edema of the root of the right arm associated with erythrocyanosis of the extremity and collateral circulation of the shoulder. History taking revealed oral contraception and recent change in violin playing habits. D-dimers were negative. A second duplex-Doppler was required before visualization of a DVT in the right subclavian vein. The patient was given low-molecular-weight heparin alone, followed by rivaroxaban. The outcome was very favorable at 48h. The patient was seen at 4 months and had not had a recurrent episode.
The diagnosis of DVT of the upper limb is basically clinical. There is a clinical probability score for the introduction of anticoagulation even if the duplex-Doppler fails to visualize DVT, a situation that can occur due to the clavicular superposition in this region. Exercise-induced DVT should be suspected in patients with minimally intense but repeated exercise (hyper-abduction), e.g. as here playing the violin. Anticoagulation is the treatment of choice. The role for surgery and pharmacomechanical strategies remains to be defined.
Exercise-induced thrombosis (Paget-Schroetter syndrome) should be suspected in young patients free of any comorbidity who develop a thrombosis of the upper limb. Studies comparing different therapeutic options would be useful to achieve more homogeneous management practices despite the heterogeneous clinical presentations.
运动诱发的血栓形成是上肢深静脉血栓形成（DVT）的罕见原因，通常影响无合并症的年轻受试者。诊断可能具有挑战性。
一名23岁的右利手法国女性教师兼业余小提琴手，出现右臂根部水肿，伴有肢体红绀和肩部侧支循环。病史询问发现其正在服用口服避孕药且近期小提琴演奏习惯有改变。D-二聚体检测结果为阴性。在右锁骨下静脉的DVT显影之前，需要进行第二次双功多普勒超声检查。该患者仅接受了低分子肝素治疗，随后服用利伐沙班。48小时时预后非常良好。4个月后对患者进行随访，未出现复发情况。
上肢DVT的诊断基本依靠临床症状。即使双功多普勒超声未能显示DVT，也有用于指导抗凝治疗的临床概率评分，出现这种情况可能是由于该区域锁骨的重叠遮挡。对于进行轻微但重复运动（过度外展）的患者，如本例中的小提琴演奏者，应怀疑运动诱发的DVT。抗凝是首选治疗方法。手术和药物机械治疗策略的作用仍有待确定。
对于无任何合并症却发生上肢血栓形成的年轻患者，应怀疑运动诱发的血栓形成（佩吉特-施罗特综合征）。尽管临床表现各异，但比较不同治疗方案的研究将有助于实现更统一的管理实践。
