Paget-Schroetter syndrome in 21 children: outcomes after multidisciplinary care

Management of Paget-Schroetter Syndrome: a Systematic Review and Meta-Analysis

OBJECTIVE

Currently, there is no consensus on the optimal management of Paget-Schroetter syndrome (PSS). The objective was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies.

DATA SOURCES

The Cochrane, PubMed, and Embase databases were searched for reports published between January 1990 and December 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted following PRISMA 2020 guidelines. The primary endpoint was the proportion of symptom free patients at last follow up. Secondary outcomes were success of initial treatment, recurrence of thrombosis or persistent occlusion, and patency at last follow up. Meta-analyses of the primary endpoint were performed for non-comparative and comparative reports. The quality of evidence was assessed using the GRADE approach.

RESULTS

Sixty reports were included (2 653 patients), with overall moderate quality. The proportions of symptom free patients in non-comparative analysis were: anticoagulation (AC), 0.54; catheter directed thrombolysis (CDT) + AC, 0.71; AC + first rib resection (FRR), 0.80; and CDT + FRR, 0.96. Pooled analysis of comparative reports confirmed the superiority of CDT + FRR compared with AC (OR 13.89, 95% CI 1.08 - 179.04; p = .040, I2 87%, very low certainty of evidence), AC + FRR (OR 2.29, 95% CI 1.21 - 4.35; p = .010, I2 0%, very low certainty of evidence), and CDT + AC (OR 8.44, 95% CI 1.12 - 59.53; p = .030, I2 63%, very low certainty of evidence). Secondary endpoints were in favour of CDT + FRR.

CONCLUSION

Non-operative management of PSS with AC alone results in persistent symptoms in 46% of patients, while 96% of patients managed with CDT + FFR were symptom free at end of follow up. Superiority of CDT + FRR compared with AC, CDT + AC, and AC + FRR was confirmed by meta-analysis. The overall quality of included reports was moderate, and the level of certainty was very low.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget Schroetter Syndrome

BACKGROUND

Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome- PSS) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT) followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer based upon response. The aim of this study was to evaluate outcomes of this flexible protocol.

METHODS

Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. Endpoints included success of TL and eventual clinical outcome. Patients were divided into 2 groups-Group I: TL/PMT + TOD; Group II: medical management/anticoagulation + TOD.

RESULTS

PSS was diagnosed in 114 patients; 104 (62 female, mean age 31 years) who underwent TOD were included in the study. Group I: 53 patients underwent TOD after initial TL/PMT (23 at our institution and 30 elsewhere) with success (acute thrombus resolution) in 80% (n = 20) and 72% (n = 24) respectively. Adjunctive balloon-catheter venoplasty was performed in 67%. TL failed to recanalize the occluded SCV in 11% (n = 6). Complete thrombus resolution was seen in 9% (n = 5). Residual chronic thrombus in 79% (n = 42) resulted in median SCV stenosis of 50% (range 10% to 80%). With continued anticoagulation, further thrombus retraction was noted with median 40% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range 2-8 months). Rethrombosis of the SCV occurred in 3 patients 1-3 days postoperatively and was managed with MT/SCV stenting/balloon angioplasty and anticoagulation. Symptomatic relief was achieved in 49/53 (92%) patients at a median follow-up of 14 months. Group II: 51 patients underwent TOD following medical treatment elsewhere with anticoagulation alone for an average 6 months (range 2-18 months) with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (76%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in 4 patients (7%); the indication for TOD being residual symptoms from compression of collateral veins, the median residual stenosis was 70% (range 30-90%). TOD was performed at a median of 6 months after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in 4 patients and stenting in 2. Symptomatic relief was achieved in 46/51 (90%) at a median follow-up of 24 months.

CONCLUSIONS

For Paget Schroetter syndrome a management protocol encompassing elective thoracic outlet decompression at a convenient time following thrombolysis is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the subclavian vein and may reduce the need for open venous reconstruction.

Venous thoracic outlet syndrome and Paget-Schroetter syndrome

Venous thoracic outlet syndrome represents a relatively rare but important diagnosis in the adolescent population with increasing recognition. Compression of the subclavian vein within the costoclavicular space can lead to episodic venous outlet obstruction in the upper extremity, with edema, rubor and functional symptoms. Over time, cumulative injury and compression can lead to thrombosis of the vein, referred to as "effort thrombosis" or the Paget-Schroetter syndrome. This progression can lead to the need for acute management of the venous thromboembolism, requirement for thoracic outlet decompression surgery and the potential for long-term sequelae such as post-thrombotic syndrome. Management is focused on clot minimization, anticoagulation during the period of endothelial injury and inflammation and surgical decompression via first rib resection, anterior scalenectomy and venolysis to remove external compression of the vein. This manuscript reviews the diagnosis, evaluation and treatment of venous thoracic outlet syndrome and Paget-Schroetter syndrome.

Successful Use of Apixaban for Paget-Schroetter Syndrome in a Pediatric Patient

Paget-Schroetter syndrome (PSS) is a rare syndrome that typically develops in young, healthy males subjected to repetitive overhead motions resulting in compression and thrombosis of the subclavian vein. This "effort thrombosis" typically occurs acutely in patients with specific anatomic variations within the thoracic outlet and is treated by a combination of surgical and pharmacologic interventions. There is a paucity of literature regarding this syndrome, particularly surrounding pharmacotherapy, and in the treatment of pediatric patients. This case report documents the pharmacologic treatment of a 17-year-old, male, baseball player with confirmed PSS. Apixaban was selected as the anticoagulant therapy of choice following the determination of its safety and anticipated efficacy for this pediatric patient. Upon admission, anticoagulation was initiated with intravenous heparin and transitioned to warfarin for 1 dose. On day 2, the patient was discharged with apixaban 10 mg twice daily for 7 days, followed by 5 mg twice daily. One week later, he underwent catheter-directed thrombectomy, followed by thoracic outlet decompression with resection of the first rib. Apixaban therapy was continued for 10 weeks after the procedure to diminish the risk of any further thrombotic events. This pediatric patient with PSS was successfully treated with apixaban in conjunction with surgical management. Treatment with apixaban resulted in continued resolution of thrombus after follow-up, with no complications reported thereafter. Further research is needed to definitively determine the safety and efficacy of apixaban for the use of pediatric anticoagulation, particularly in upper extremity deep vein thrombosis.

A systematic review and meta-analysis for the management of Paget-Schroetter syndrome

OBJECTIVE

There is currently no general agreement on the optimal treatment of Paget-Schroetter syndrome. Most centers have advocated an interventional approach that is based on the results of small institutional series. The purpose of our meta-analysis was to focus on the safety and efficacy of thrombolysis or anticoagulation with decompression therapy. A detailed description of the epidemiologic, etiologic, and clinical characteristics, along with radiologic findings and treatment option details, was also performed.

METHODS

The current meta-analysis was conducted using the PRISMA guidelines. Studies reporting on spontaneous thrombosis or thrombosis after strenuous activities of axillary-subclavian vein were considered eligible. Analyses of all retrospective studies were conducted, and pooled proportions with 95% confidence intervals of outcome rates were calculated.

RESULTS

Twenty-five studies with 1511 patients were identified. Among these patients, 1177 (77.9%) had thrombolysis, 658 (43.5%) had anticoagulation, and 1293 (85.6%) patients had decompression therapy of the thoracic outlet. Complete thrombus resolution was estimated at 78.11% of the patients after thrombolysis, and the respective pooled proportion for partial resolution of thrombus was 23.72%. Despite thrombolytic therapy, 212 patients underwent additional balloon angioplasty for residual stenosis, although only 36 stents were implanted. After anticoagulation, a total of 40.70% of the patients had complete thrombus resolution, whereas partial resolution was occurred in 29.13% of the patients. During follow-up, a total of 51.75% of the patients with any initial treatment modality had no remaining thrombus, and 84.87% of these patients were free of symptoms. We also estimated that 76.88% of the patients had a Disabilities of the Arm, Shoulder and Hand score of <20, indicating no or mild symptoms after treatment. A subgroup meta-analysis with 20 studies and 1309 patients, showed significantly improved vein patency and symptom resolution in patients who had first rib resection with or without venoplasty, compared with those who had only thrombolysis.

CONCLUSIONS

Although no randomized controlled data are available, our analysis strongly suggested higher rates of thrombus and symptoms resolution with thrombolysis, followed by first rib resection. A prospective randomized trial comparing anticoagulants with thrombolysis and decompression of thoracic outlet is required.

Upper Extremity Compressive Neuropathies in the Pediatric and Adolescent Populations

PURPOSE OF REVIEW

Although somewhat rare, upper extremity compressive neuropathies can occur in the pediatric and adolescent populations due to various etiologies. Some of the most common conditions seen include thoracic outlet syndrome, supracondylar process syndrome, cubital tunnel syndrome with subluxation of the ulnar nerve, and carpal tunnel syndrome. This review will focus on these diagnoses and how to address them in the pediatric and adolescent populations.

RECENT FINDINGS

Due to the rarity of upper extremity compressive neuropathies in the pediatric and adolescent populations, substantial advancement in the literature does not routinely occur. However, recent literature has found a difference in the rate of various subtypes of thoracic outlet syndrome in children versus adults. Additionally, cubital tunnel syndrome associated with ulnar nerve subluxation/instability has recently been found to have better outcomes following surgical decompression of the ulnar nerve and transposition than those with stable ulnar nerves. In summary, this review provides the most recent knowledge surrounding upper extremity compressive and entrapment neuropathies in the pediatric and adolescent populations.

Paget-Schroetter Syndrome: a case report of diagnosis, treatment, and outcome in a healthy 18-year-old athletic swimmer

Paget-Schroetter Syndrome is a rare condition in the spectrum of deep vein thromboses involving spontaneous upper extremity venous thrombosis in the axillary-subclavian vein. The syndrome usually occurs in young, healthy individuals and is a progressive, anatomic manifestation of venous thoracic outlet syndrome. Thrombosis is secondary to repetitive overuse of the arm, leading to compression, microtrauma, and local inflammation of the particularly vulnerable subclavian vein in the thoracic outlet at the junction of the first rib and clavicle. The condition is often misdiagnosed because of its rarity and can lead to significant disability and morbidity if treatment is delayed. In this case report, Paget-Schroetter Syndrome, causing significant pain and dysfunction, is presented in an 18 year-old female freestyle-swimmer that was successfully treated with anticoagulation, thrombolysis, thoracic outlet decompression and first rib resection, scalenectomy, venolysis, and venoplasty. Early suspicion of this condition can lead to prompt diagnosis, and subsequent aggressive interventional treatment with catheter-directed thrombolysis and thoracic outlet decompression, in addition to anticoagulation, demonstrated success in achieving complete resolution of symptoms in this case.

Treatment-Related Outcomes in Paget-Schroetter Syndrome-A Cross-Sectional Investigation

OBJECTIVE

To investigate treatment-related outcomes, namely radiological clot resolution, post-thrombotic syndrome (PTS), and health related quality-of-life (HRQoL) scores, in children with Paget-Schroetter syndrome (PSS) undergoing multidisciplinary management, including anticoagulation and decompressive rib-resection surgery, with or without thrombolytic therapy.

STUDY DESIGN

We identified all patients treated for PSS at our institution between the years 2010 and 2017. Baseline clinical and radiologic data were abstracted from medical records. Two validated survey instruments to quantify PTS and HRQoL were mailed to eligible patients. Standard statistical methods were used to summarize these measures.

RESULTS

In total, 22 eligible patients were identified; 10 were treated with thrombolysis followed by anticoagulation and rib resection, and 12 were treated with anticoagulation and rib resection alone. Nineteen patients responded to the survey instruments. Median age at deep vein thrombosis diagnosis and survey completion were 16.3 and 20.4 years, respectively. Nineteen of 22 patients had thrombus resolution on radiologic follow-up. Fourteen of 19 survey respondents reported signs/symptoms of PTS of which the majority (12/14) reported mild PTS. Aggregate total, physical, and psychosocial HRQoL scores reported were 90.6, 96.7, and 93.3, respectively. Thrombolytic therapy was not associated with a significant improvement in radiologic, clinical or HRQoL outcomes.

CONCLUSIONS

Most patients with PSS had complete thrombus resolution on imaging. Only 11% of survey respondents reported moderate PTS. The entire cohort reported excellent HRQoL scores. The role for thrombolytic therapy in the management of childhood PSS remains incompletely elucidated.

How We Manage Pediatric Deep Venous Thrombosis

Over the past two decades, the incidence and recognition of venous thromboembolism (VTE) in children has significantly increased, likely as a result of improvements in the medical care of critically ill patients and increased awareness of thrombotic complications among medical providers. Current recommendations for the management of VTE in children are largely based on data from pediatric registries and observational studies, or extrapolated from adult data. The scarcity of high-quality evidence-based recommendations has resulted in marked variations in the management of pediatric VTE among providers. The purpose of this article is to summarize our institutional approach for the management of VTE in children based on available evidence, guidelines, and clinical practice considerations. Therapeutic strategies reviewed in this article include the use of conventional anticoagulants, parenteral targeted anticoagulants, new direct oral anticoagulants, thrombolysis, and mechanical approaches for the management of pediatric VTE.