Failure of Wallstents in the subclavian vein due to stent damage

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.

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.

Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet

OBJECTIVE

Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy.

METHODS

We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection.

RESULTS

During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months.

CONCLUSIONS

Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.

Imaging of the Patient with Thoracic Outlet Syndrome

Patients with symptoms from compression of the neurovascular bundle in the thoracic outlet are described as having thoracic outlet syndrome (TOS), which is best thought of as three conditions classified according to which structures are involved. The purpose of this article is to review the role of imaging in evaluation of patients with TOS, beginning with diagnosis and extending through postoperative management. While diagnosis of TOS still rests on the patient's presenting history and physical examination, imaging examinations are helpful in supporting the diagnosis, delineating abnormal anatomy, determining which structures are compressed, identifying the site of compression, and excluding other diagnoses. Magnetic resonance imaging is the noninvasive imaging modality of choice in evaluating patients with suspected TOS, but computed tomography also plays an important role, particularly in delineating bone anatomy. Evidence of vascular damage is required to make the diagnosis of TOS at imaging. Dynamic compression of the axillosubclavian vessels at the thoracic outlet can be a finding supportive of the diagnosis of TOS but is not a stand-alone diagnostic criterion, as it can be seen in patients without TOS. As diagnosis and treatment of TOS increase, radiologists will increasingly encounter the TOS patient after decompression surgery. Recognition of the expected postoperative appearance of these patients is critical, as is an understanding of the imaging findings of potential short- and long-term complications. (©)RSNA, 2016.

Effort thrombosis presenting as pulmonary embolism in a professional baseball pitcher

Context:

Effort thrombosis, or Paget-Schroetter’s syndrome, is a rare subset of thoracic outlet syndrome in which deep venous thrombosis of the upper extremity occurs as the result of repetitive overhead motion. It is occasionally associated with pulmonary embolism. This case of effort thrombosis and pulmonary embolus was in a 25-year-old major league professional baseball pitcher, in which the only presenting complaints involved dizziness and shortness of breath without complaints involving the upper extremity—usually, a hallmark of most cases of this condition. The patient successfully returned to play for 5 subsequent seasons at the major league level after multimodal treatment that included surgery for thoracic outlet syndrome.

Objective:

Though rare, effort thrombosis should be included in the differential diagnosis of throwing athletes with traditional extremity-focused symptoms and in cases involving pulmonary or thoracic complaints. Rapid diagnosis is a critical component of successful treatment.

Migration of superior vena cava stent

There has been a recent increase in the use of endovascular prostheses resulting in complex surgical and interventional complications not previously recognised. We report a case of Superior vena cava stenosis treated with a wallstent which migrated to the right atrium, necessitating a combined radiological and surgical approach to retrieve it.

Diagnosis and Management of Subclavian Vein Thrombosis: Three Case Reports and Review of Literature

Axillosubclavian vein thrombosis is seen relatively infrequently in clinical practice when compared with lower limb deep-venous thrombosis; however, it is a condition that can result in significant morbidity if managed suboptimally. A multimodal treatment approach has been increasingly adopted with thrombolysis and/or thoracic outlet decompression being favored over anticoagulation alone, although the evidence base to support this approach is limited. In all, 3 cases are reported, which highlight numerous pertinent issues relating to the diagnostic and therapeutic options available.

Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty

OBJECTIVE

Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage.

METHODS

Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months.

RESULTS

Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis.

CONCLUSIONS

Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.

Venous thoracic outlet syndrome

Venous thoracic outlet syndrome is caused by subclavian vein obstruction with or without thrombosis. The primary symptom is arm swelling, frequently accompanied by cyanosis, pain, and occasionally paresthesias. Venography is the only reliable diagnostic tool. Therapy has three goals: (1) remove the thrombus (in thrombotic cases), (2) remove the extrinsic compression, and in a minority of cases, (3) remove the intrinsic stenosis.

Endovascular management of venous thrombotic diseases of the upper torso and extremities

Central venous thrombosis in the upper torso can be either primary, occurring as a result of longstanding extrinsic compression, or secondary, resulting from an acquired intrinsic occlusive disease or foreign body. As in lower extremity deep vein thrombosis (DVT), anticoagulation therapy is the mainstay of therapy in upper torso and upper extremity DVT. However, in the presence of severely symptomatic acute thrombosis, pharmacologic and/or mechanical thrombolytic therapy represent the main invasive form of therapy for these conditions. After clearance of the acute thrombotic component, definitive management in patients with underlying anatomic abnormalities can be undertaken. Primary subclavian axillary vein thrombosis caused by extrinsic obstruction at the thoracic outlet is treated with thrombolytic therapy and anticoagulation followed by surgical decompression, whereas secondary causes of central venous obstruction and thrombosis are usually amenable to endovascular treatment with balloon angioplasty and stent placement. Postoperative interval anticoagulation is usually recommended. In addition to clinical follow-up, imaging follow-up with duplex sonography or conventional venography is usually recommended to assess the presence of restenosis and/or residual compression.

Vascular Thoracic Outlet Syndrome

Vascular thoracic outlet syndrome generally affects young, active, otherwise healthy patients. The diagnosis is suspected by clinical presentation, and can be confirmed with angiography or venography. Conservative management has been associated with significant morbidity and long-term residual disability. We have used a multimodal treatment protocol that includes thrombolysis, anticoagulation, surgical decompression, and interventional procedures. Catheter-directed recombinant tissue-type plasminogen activator and intravenous heparin infusion are instituted at the time of diagnosis to promote recanalization and prevent propagation of thrombus. Surgical decompression of the thoracic outlet can be readily achieved by first rib resection during the same hospitalization. Postoperative venograms are obtained in all patients. Residual stenoses can be managed with angioplasty alone in some patients but more commonly require stent placement. We believe thrombolysis, anticoagulation, surgical decompression, and percutaneous interventions act synergistically to improve results of therapy in patients with vascular thoracic outlet syndrome.