Venous thoracic outlet syndrome (Paget-Schroetter syndrome):
Venous thoracic outlet syndrome occurs when there is compression of the subclavian vein between the clavicle and the first rib. This will often occur in the setting of vigorous activity involving an overhead motion of the arm, as is common among baseball pitchers, surfers, swimmers and weightlifters and may also occur when supporting a heavy weight on the shoulder. It is not uncommon, however, to not have any identifiable cause and some patients with venous thoracic outlet syndrome don™t fall into any of these categories. There are many muscles in this area and with exercise these muscles may grow larger constricting the vein in the tight confines of the thoracic outlet. This compression may lead to thrombosis or clotting of the subclavian vein and this then leads, predictably, to arm discomfort and swelling. There is some debate over the best course of treatment. At the San Francisco Vein and Vascular Institute we will, in most cases, proceed with initial venous thrombolysis which is a procedure whereby a catheter is placed within the clotted vein delivering medication that dissolves the clot. While this serves to eliminate the clot and improve the symptoms this procedure does not address the underlying cause of the thrombosis. But with the clot cleared away we are able to confirm the diagnosis of the venous thoracic outlet syndrome. We then may recommend moving forward with a first rib resection. This opens the thoracic outlet definitively removing the forces compressing the vein.
Renal artery stenosis and renovascular hypertension:
High blood pressure (hypertension) may be the consequence of renal artery stenosis. The renal artery is the artery that carries blood to the kidney. A stenosis is a partial blockage of this artery. Our kidneys help to regulate our blood pressure. When the artery is partially blocked the kidney is tricked into thinking the blood pressure is low, when in fact, it is only low in the kidney. The kidney then releases renin which triggers the high blood pressure. While this is far from the most common cause of hypertension this is the one cause that can be treated without relying on medications. If we suspect that a patient may have a renal artery blockage we will initially screen this patient with an ultrasound. This can be performed in the office. If the stenosis is significant we will in some cases recommended angiography and intervention with either angioplasty alone or angioplasty in combination with a stent. The plan to treat this condition is frequently made in conjunction with the patient’s nephrologist or cardiologist and primary care physician. The treatment of this problem demands a team approach as there are many factors that can lead to hypertension and these all must be considered and medications adjusted in coordination with physicians that specialize in this area.