Ilhan et al J Clin Med Res • 2009;1(3):178-180 Figure 2. Longitudinal color Doppler sonogram reveals near com- plete thrombotic occlusion of the left subclavian vein. Figure 4. Transverse color Doppler image demonstrates promi- nent cervical venous collateralisation. showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein (Fig. 2). Thrombosis extended into the proximal segment of the left internal jugular vein (IJV) (Fig. 3). Furthermore, ex- tensive venous collateral formations were presented in the left proximal cervical localization (Fig. 4). Both MR angio- graphic and sonographic findings were consistent with PSS. As the patient had already developed extensive venous collaterals, no surgical intervention was performed. Instead, treatment with low-molecular weight heparin and anticoagu- lants, was initiated and continued along with the follow-up for bleeding parameters. As of 3 years clinical follow-up, the patient is doing well and the treatment is continued with oral anticoagulants and acetylsalicylic acid. Figure 3. Transverse color Doppler image shows extension of the thrombotic material into the proximal part of the internal jugular vein. Discussion Spontaneous thrombosis in the upper-extremity veins was first described by Sir James Paget in 1875. Later, in 1884, Von Schroetter associated this condition with throm- botic occlusion of the axillary vein and the subclavian vein [4]. Spontaneous or effort-related thrombosis of the axillo- subclavian vein is referred to as PSS, the disease of actively working young men. Around 75% of the cases usually occur in the dominant upper extremity after extraordinary arm po- sition or exercise. Shoulder movements aggravate the com- plaints [5, 6]. Although it is more frequent among male ath- letes, today, it also occurs among women engaging in sport activities [1]. These patients are likely to have lowered living standards in the later years of their life with disease sequelae continuing throughout their lives [7]. PSS should be considered in all young patients actively working, engaging in sports and presenting with unilateral swelling of the arm. Patient histories often include using one arm with frequently repeated movements. Usually, the domi- nant arm is affected [7]. In our case, the thrombotic material was shown to extend into the proximal left internal jugular vein. To our knowledge, extension of subclavian venous thrombosis thor- ough the IJV in PSS is exceptionally rare and has been re- ported only in one recently published article [8]. Early diagnosis is crucial for rapid venous recanaliza- tion through anticoagulant treatment. Indications for surgical treatment in PSS remain con- troversial. As soon as early diagnosis is available, a multidis- ciplinary approach is needed [4]. Treatment methods might change with personal, institutional, and regional preferences. Treatment involves surgical procedures such as cath- Articles © The authors, Journal compilation © J Clin Med Res and Elmer Press™, www.jocmr.org 179