Surgical intervention is not required for all patients with subclavian vein thrombosis

Thrombolysis and Surgical Decompression for Venous Thoracic Outlet Syndrome

INTRODUCTION

Treatment for venous thoracic outlet syndrome (vTOS) includes thrombolysis followed by decompressive rib resection. Given the rarity of the disease, the goal of this study was to describe current practices in treatment of vTOS.

METHODS

All patients with diagnoses of subclavian vTOS who underwent rib resection in the 2018-2020 Nationwide Readmissions Database were included in this study. Patients were grouped based on number of days between thrombolysis and by number of hospitalizations: thrombolysis followed by surgery in the same hospitalization was considered "simultaneous" and in separate hospitalizations was "staged."

RESULTS

Five hundred ninety patients met the inclusion criteria. The average age was 34.1 ± 13.3 y, and 42.9% (253 of 590) were female. Among the patients receiving thrombolysis and decompressive rib resection, 46.8% (164 of 350) patients had <14 d between interventions, 19.1% (67 of 350) patients had 14-30 d between interventions, and 34.0% (119 of 350) had >30 d between interventions. There were no significant differences in postoperative bleeding between patients with <14 d, 14-30 d, and >30 d between thrombolysis and surgery. In terms of number of hospital visits, 19.0% (112 of 590) had "simultaneous" thrombolysis and surgery and 40.5% (239 of 590) had thrombolysis and surgery in a "staged" approach. Forty point five percent (239 of 590) of patients received only surgical decompression without thrombolysis.

CONCLUSIONS

Thrombolysis followed by first rib resection for vTOS can be performed during the same hospital admission without an associated risk of bleeding complications.

Paget-Schroetter Syndrome: A Case of a Young Weightlifter

Venous thoracic outlet syndrome is a rare type of thoracic outlet disorder that is often overlooked. When an upper extremity deep vein thrombosis (UEDVT) occurs due to thoracic outlet compression, it is commonly referred to as Paget-Schroetter syndrome (PSS). The space between the first rib and the clavicle where the subclavian vein passes through is highly vulnerable to compression and injury. This space often undergoes repetitive trauma due to extrinsic compression which ultimately results in scarring and clot formation. This case report reviews the case of a 26-year-old white male who presented with the chief complaint of right arm swelling and soreness after strenuous bench pressing. He went to urgent care and the initial diagnosis was a strained muscle. An ultrasound was ordered, revealing multiple UEDVTs. At this time, the patient was referred to vascular surgery for further management. Recommended management for PSS is to initiate anticoagulation or thrombolytic therapy depending on the timing between the onset of symptoms and diagnosis. Although there is some disagreement on the next steps after thrombolysis, most physicians agree that decompression of the thoracic outlet with first rib resection is the logical next step to prevent clot recurrence. The patient received the above-mentioned therapy and is progressing well with recovery. Recognizing the thoracic outlet as a potential location for pathology and keeping in mind those who have a presentation similar to this case study is extremely important.

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.

Chronic Pain Considerations in Patients with Cardiovascular Disease

Cardiovascular disease affects close to half of the United States population and many of these patients will develop chronic pain syndromes as a result of their disease process. This article provides an overview of several pain syndromes that result, directly or indirectly, from cardiovascular disease including peripheral arterial disease, angina, thoracic outlet syndrome, postamputation pain, complex regional pain syndrome, and poststroke pain. Psychological and medical comorbidities that affect the medical decision-making process in the treatment of chronic pain associated with cardiovascular disease are also discussed.

Idiopathic upper extremity deep vein thrombosis: A systematic review

BACKGROUND

Idiopathic upper extremity deep vein thrombosis (UEDVT) management is controversial and ranges from anticoagulation alone to the addition of further interventions such as thrombolysis and decompressive surgery.

OBJECTIVES

The objective of this systematic review was to assess the effects of anticoagulation alone compared to anticoagulation with additional interventions such as thrombolysis or decompressive surgery on the incidence of recurrent UEDVT and post-thrombotic syndrome (PTS) in patients with idiopathic UEDVT (including those associated with the oral contraceptive pill).

PATIENTS/METHODS

A systematic search was conducted for studies which focused on acute UEDVT treatment defined as therapies starting within 4 weeks of symptom onset. We limited studies to those that recruited 10 or more subjects and involved at least 6 weeks to 12 months anticoagulation alone or together with additional interventions with at least 6-month follow-up. Primary outcomes were symptomatic recurrent radiologically confirmed UEDVT and PTS. Secondary outcomes were symptomatic venous thromboembolism, bleeding and mortality.

RESULTS

We found seven studies which reported recurrent UEDVT rates and five that reported PTS rates. All studies were retrospective or cross-sectional. None compared anticoagulation alone to anticoagulation with additional intervention. Study heterogeneity precluded meta-analysis and risk of bias was moderate to serious. Recurrent UEDVT occurred in 0% to 12% post-anticoagulation alone and 0% to 23% post-additional interventions. PTS rates varied from 4% to 32% without severe PTS. Only limited studies reported on our secondary outcomes.

CONCLUSION

There is limited evidence behind idiopathic UEDVT management. Prospective comparative studies in this area are essential.

Upper Extremity Deep Venous Thrombosis: Etiologies, Diagnosis, and Updates in Therapeutic Strategies

Upper extremity deep vein thrombosis (UEDVT) is responsible for 4 to 10% of all deep vein thrombosis (DVT). Untreated UEDVT can lead to significant disability secondary to the postthrombotic syndrome. To date, there are no randomized trials specifically comparing different therapeutic strategies. Ultimately, optimal management of UEDVT depends on the underlying etiology, patient symptoms, and degree of thrombosis, with supporting evidence primarily extrapolated from lower extremity DVT data. This article will review the classification, presentation, and diagnosis of both primary and secondary UEDVT. In addition, it will discuss updates in clinical guidelines, anticoagulation, endovascular and surgical treatment strategies.

Upper Extremity Deep Vein Thrombosis: Current Knowledge and Future Directions

Upper extremity deep vein thrombosis (UEDVT) has been increasing in incidence due to the escalating use of central venous catheters such as peripherally inserted central catheters. UEDVT can be primary idiopathic or secondary to pacemaker leads, intravascular catheters or cancer. In comparison to conventional venous thromboembolism such as lower limb deep vein thrombosis or pulmonary embolism the risk factors, investigations, and management are not well defined. We review current evidence in primary and secondary UEDVT, highlighting areas in need of further research. We also explore the entity of venous thoracic outlet syndrome, which is said to be a risk factor for recurrent primary UEDVT and is the rationale behind surgical interventions.

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.

Long-term outcome after nonsurgical management of Paget-Schroetter syndrome

OBJECTIVE

Paget-Schroetter syndrome (PSS) is an uncommon disease with potentially debilitating long-term effects. The optimal therapy for PSS is unclear, and the role of surgical decompression of the thoracic outlet is still being questioned. In this study, we present long-term results of patients treated with catheter-directed thrombolysis (CDT) and anticoagulation without surgical management.

METHODS

This is a retrospective case series of all patients who previously underwent treatment of PSS in our institution between the years 2007 and 2019. Patients were evaluated for clinical signs of post-thrombotic syndrome (PTS) using a modified Villalta scoring scale, including measurements of the circumference of the treated and untreated arms. Duplex ultrasound examination of the treated vein was performed, and quality of life was evaluated using the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire.

RESULTS

Eighteen consecutive patients previously treated for PSS with CDT and anticoagulation compose the cohort of this study. None underwent surgical thoracic outlet decompression. All were contacted and invited for clinical and ultrasound evaluation. Follow-up was available for all patients. Mean age at diagnosis was 29 years (range, 16-46 years), and 15 (79%) were male. Mean time from the index event to the follow-up clinic visit was 109 months (range, 37-176 months). Patients were treated with anticoagulation for a mean period of 26 months (range, 6-120 months). Seventeen patients (94%) had a Villalta score of 0 to 3, consistent with nonexistence of PTS. Fourteen patients (78%) were completely asymptomatic. Seven patients (39%) had no difference in arm circumference. A difference in arm circumference between the treated arm and the healthy arm of 1 cm and 2 cm was seen in nine (50%) and two (11%) patients, respectively. Based on the shortened Disabilities of the Arm, Shoulder, and Hand score, none of the patients suffered from impaired quality of life. Duplex ultrasound scanning of the affected veins was performed on 16 of the 18 patients (89%). The vein appeared patent in all examined patients. In three patients, the wall of the examined vein was thickened and irregular.

CONCLUSIONS

This study suggests that PSS patients can be treated with anticoagulation and CDT alone, without the need for surgical thoracic outlet decompression. This is based on long-term follow-up of these patients objectively evaluated by means of valid scoring systems. These findings suggest that symptoms or signs of PTS rarely develop, the patients do not suffer from impaired quality of life, and patency of the diseased vein is commonly maintained.

Paget-Schroetter syndrome: A contemporary review of the controversies in management

Aim

To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome.

Materials and methods

We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome.

Results

There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed.

Conclusions

Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.

The infraclavicular approach for Paget-Schroetter syndrome

Introduction Paget-Schroetter syndrome is a rare effort thrombosis of the axillary-subclavian vein, mainly occurring in young male patients. Current management involves immediate catheter directed thrombolysis, followed by surgical decompression of the subclavian vein. This has been invariably performed using a transaxillary or supraclavicular approach. However, the subclavian vein crosses the first rib anteriorly just behind the manubrium and can also be accessed via an infraclavicular incision. Methods MEDLINE® and Embase™ were searched for all studies on outcomes in patients undergoing infraclavicular first rib resection for treatment of Paget-Schroetter syndrome. Measured outcomes included freedom from reintervention, secondary patency and symptom resolution. Studies on neurogenic, arterial and iatrogenic venous thoracic outlet syndrome were not included. Findings Six studies (involving 268 patients) were eligible. The overall secondary venous patency rate was 98.5%. There was freedom from reintervention in 89.9% of cases and among those patients with reocclusion, 84.0% had chronic thrombosis (symptom duration >14 days), with 76.2% having a venous segment stenosis of >2cm. Only 3 of the 27 patients remained occluded despite reintervention. The infraclavicular approach provides excellent exposure to the subclavian vein and allows reconstruction when required. Moreover, this approach enables complete resection of the extrinsic compression that precipitated the initial thrombotic event, with excellent long-term patency rates. In conclusion, the infraclavicular route may have significant advantages compared with the transaxillary or supraclavicular approaches for successful and durable treatment of Paget-Schroetter syndrome.

Clinical course of upper extremity deep vein thrombosis in patients with or without cancer: a systematic review

BACKGROUND

The incidence of upper extremity deep vein thrombosis (UEDVT) is increasing. Information on the clinical course of UEDVT is scarce, especially in cancer patients.

AIM

To summarize the clinical evidence regarding long-term clinical outcomes of UEDVT, in terms of recurrent venous thromboembolism (VTE), mortality, and anticoagulant-related bleeding, in patients with or without concomitant cancer.

METHODS

A systematic search of the literature was conducted in MEDLINE, EMBASE and BIOSIS Previews. Incidence rates for all outcome variables were calculated.

RESULTS

In total, 45 studies comprising 4580 patients were included. No randomized controlled trials were identified. In most studies, patients were treated solely with anticoagulants. Among the prospective studies, the incidences of recurrent VTE and bleeding complications averaged 5.1% and 3.1% respectively, during 3 to 59months of follow-up. In the retrospective studies these figures were 9.8% and 6.7% respectively. Among the prospective studies, the mortality rate was 24% after one year. In the retrospective studies this rate was 35%. Cancer patients were found to have a 2- to 3-fold higher risk of recurrent VTE, an 8-fold increased risk of mortality, and a 4-fold increased risk of bleeding during anticoagulant therapy, compared to non-cancer patients.

CONCLUSIONS

Studies were very heterogeneous in terms of study design, study populations and treatment approaches. Follow-up durations varied greatly, hampering combined analyses of average incidence rates. There is a need for large prospective studies to provide information on the best management of this disease, especially in high risk groups such as those with cancer.

An Integrative Review of Outcomes in Patients with Acute Primary Upper Extremity Deep Venous Thrombosis Following No Treatment or Treatment with Anticoagulation, Thrombolysis, or Surgical Algorithms

Primary upper extremity deep venous thrombosis (UEDVT) is a rare condition that typically affects young patients and can cause considerable long-term morbidity. Proposed treatments have included rest, heat, elevation of the affected limb, anticoagulation, thrombolysis, surgical decompression, percutaneous transluminal angioplasty (PTA), and stenting. However, the optimal management of primary UEDVT remains controversial. This study was an integrative review of the English-language literature since 1965 on primary UEDVT, with comparison of long-term symptoms, rethrombosis, and pulmonary embolism in 4 treatment algorithms: rest, heat, and elevation alone; anticoagulation alone; surgical decompression without thrombolysis; and algorithms including thrombolysis. Forty-one studies describing 559 patients met the criteria for inclusion. Statistically significant differences were found among the 4 treatment algorithms in the incidence of residual symptoms (p< 0.000), the incidence of pulmonary embolism (p<0.000), and the incidence of rethrombosis (p<0.027). Residual symptoms and the severity of residual symptoms were greatest in the rest, heat, and elevation algorithm (74%), followed by the surgical (60%), anticoagulation (44%), and thrombolysis (22%) algorithms. Pulmonary embolism was also greatest in the rest, heat, and elevation algorithm (12%), followed by the anticoagulation (7%), thrombolysis (1%), and surgical algorithms (0%), while rethrombosis was greatest in the thrombolytic algorithm (7%) followed by the surgical (3%), anticoagulation (2%), and rest, heat, and elevation (0%) algorithms. These results support the current clinical practice of a staged, multidisciplinary approach to treatment of primary UEDVT that includes thrombolytic therapy and possible surgical decompression. Further studies are needed to evaluate the natural history of patients treated with thrombolysis alone, to assess the optimal timing of surgical decompression, and to determine the best use of PTA and stenting in the multidisciplinary approach.

Endovascular Management of Paget-Schroetter Syndrome

Spontaneous thrombosis of the axillary and subclavian venous segments in young, healthy adults (effort thrombosis or Paget-Schroetter syndrome) is a rare but potentially disabling affliction. The diagnosis should be suspected in any young patient presenting with unilateral arm swelling. Typically, the dominant arm is affected, and frequent, repetitive arm use is a common component of the patients' history. Although the diagnosis can often be confirmed with a venous duplex evaluation, the central location of the venous abnormality occasionally mandates cross-sectional imaging or contrast venography to confirm the diagnosis. The underlying pathophysiology of this disorder is felt to be repetitive venous trauma owing to arm motion in the narrow anatomic space between the clavicle and first rib. The treatment of Paget-Schroetter syndrome is controversial and varies according to individual, institutional, and regional preferences. In general, the trend is toward more aggressive endovascular treatment. Prompt anticoagulation is generally accepted as the minimal treatment offered. Catheter-directed thrombolysis has also acquired a prominent role in reestablishing venous patency. The importance of relieving the anatomic compression of the subclavian vein by first rib resection remains controversial, with some experts advocating surgical intervention in all affected patients, whereas others perform this procedure selectively in cases of persistent venous stenosis or ongoing symptoms. Angioplasty with or without stenting is generally discouraged in the absence of anatomic decompression but may play an adjunctive role in patients undergoing first rib resection.

Current management strategies and long-term clinical outcomes of upper extremity venous thrombosis

Essentials Few data exist on outcome of upper extremity deep and superficial vein thrombosis (UEDVT and UESVT). We followed 102 and 55 patients with UEDVT or UESVT, respectively, for a median of 3.5 years. Risk of recurrent venous thromboembolism was low in both diseases, and the mortality high. Postthrombotic symptoms were infrequent and cancer patients had a higher risk of recurrent VTE.

SUMMARY

Background There is scant information on the optimal management and clinical outcome of deep and superficial vein thrombosis of the upper extremity (UEDVT and UESVT). Objectives To explore treatment strategies and the incidence of recurrent venous thromboembolism (VTE), mortality, postthrombotic symptoms, and bleeding in patients with UEDVT and UESVT and to assess the prognosis of cancer patients with UEDVT. Patients/methods Follow-up of patients with UEDVT or UESVT, who were enrolled previously in a diagnostic management study. Results We followed 102 and 55 patients with UEDVT and UESVT, respectively, both for a median of 3.5 years. Anticoagulant treatment was started in 100 patients with UEDVT (98%) and in 40 (73%) with UESVT. Nine patients with UEDVT (9%) developed recurrent VTE, 26 (26%) died, 6 (8%) of 72 patients had moderate postthrombotic symptoms, and 5 (5%) experienced major bleeding. One patient with UESVT had a recurrent VTE, 18 (33%) died, none had moderate postthrombotic symptoms, and none had major bleeding. Of the cancer patients with UEDVT, 18% had recurrent VTE vs. 7.5% in non-cancer patients (adjusted hazard ratio 2.2, 95%CI 0.6-8.2). The survival rate was 50% in cancer patients with UEDVT vs. 60% in those without (adjusted HR 0.8, 95%CI 0.4-1.4). Conclusions The risk of recurrent VTE was low in patients with UEDVT, and negligible for UESVT. Mortality was high for both diseases. Postthrombotic symptoms were infrequent and mild. Anticoagulant therapy of UEDVT carried a substantial risk of major bleeding. Cancer patients had a significant risk of recurrent VTE.

Conservative management of chronic upper extremity venous outflow occlusion

Chronic upper extremity venous outflow occlusion (UEVOO) occurs frequently among hospitalized patients as a result of various anatomical or pathological etiologies. This includes venous thoracic outlet syndrome, catheter-related injury, malignancy, and hypercoagulable states. While open surgical and endovascular therapies have increasingly been utilized in managing UEVOO, many patients can still be successfully managed with non-invasive therapies. In this review, we will discuss how conservative measures such as anticoagulation and compression therapy can be applied to different causes of UEVOO. The optimal treatment of patients with chronic upper extremity occlusion can be accomplished by deciding which patients will be most likely to benefit from conservative management.

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

OBJECTIVE

To review the presentation, management, and outcomes of Paget-Schroetter syndrome (PSS) in children and propose a multidisciplinary treatment algorithm involving pediatric and vascular surgery, interventional radiology, and hematology.

STUDY DESIGN

Patients with PSS presenting between 2003 and 2013 were reviewed. Demographics, symptoms, therapies, and functional outcomes were noted. Data from early patients informed the development of a multidisciplinary treatment algorithm applied to later patients.

RESULTS

Of 21 patients, mean ± SD age was 16 ± 1.6 years and 11 (52%) were male. Of patients with complete presentation data, common symptoms were edema (84%), discoloration (58%), and pain (58%). Thrombophilia workup revealed one heterozygote for factor V Leiden, 2 patients with factor VIII elevation and 1 patient with mildly low antithrombin. The most recent 8 patients were treated according to an algorithm developed by a multidisciplinary working group through experience with the first 13 cases. All patients underwent a venogram, endovascular intervention (including 15 receiving catheter-directed thrombolysis), and operative ipsilateral thoracic outlet decompression (first rib resection, anterior scalenectomy, and venolysis). Postoperative complications included hemothorax (2), pneumothorax (1), and recurrent thrombosis (2). Follow up duration was 12 ± 9.5 months. Symptoms recurred transiently in 1 patient.

CONCLUSION

Pediatric patients with PSS can be treated successfully using a multidisciplinary treatment algorithm including anticoagulation, catheter-directed thrombolysis, and operative decompression of the thoracic outlet. Early outcomes are promising.

Comprehensive management of subclavian vein effort thrombosis

Subclavian vein (SCV) effort thrombosis, also known as the Paget-Schroetter syndrome, is a relatively uncommon condition that affects young, active, otherwise healthy individuals. It is considered a form of thoracic outlet syndrome, arising as a consequence of compression and repetitive injury of the SCV between the first rib and the overlying clavicle, as well as the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. Effort thrombosis is distinct from other forms of deep vein thrombosis with respect to pathophysiology, clinical presentation, and functional consequences, and it requires treatment considerations unique to effective management of thoracic outlet compression as well as the obstructed SCV. In this review the comprehensive management of SCV effort thrombosis is addressed, with an emphasis on current interventional radiology techniques used in conjunction with definitive surgical treatment, based on early catheter-based venography, thrombolytic therapy, and prompt paraclavicular thoracic outlet decompression with direct SCV reconstruction.

Management of proximal deep vein thrombosis

Iliofemoral DVT constitutes approximately 20-25% of lower limb DVT and represents a specific subgroup of patients at highest risk for post-thrombotic syndrome (PTS). Anticoagulation alone has no significant thrombolytic activity and has not impact on PTS prevention. Early thrombus removal has reduced PTS in uncontrolled reports and reviews but major trials are awaited. The optimal timing for treatment appear to be thrombus <2 weeks old and, methods for thrombus removal include direct open or suction thrombectomy, catheter directed thrombolysis (CDT), with or without percutaneous mechanical thrombectomy (PMT) devices. Three principle types of PMT device are in use (rotational, rheolytic and ultrasound enhanced devices) and are combined with CDT in pharmocomechanical thrombolysis (PhMT) to enhance early thrombus removal. These devices have individual device specific attributes and side effects that are additional to the bleeding complications of thrombolysis. A number of additional interventions may be utilised to the improve results of CDT and PhMT. IVC filter deployment to reduce periprocedural PE, is supported by little evidence unless an indication for its use already exists. However, balloon venoplasty and vein stents undoubtedly vein patency after treatment. Early thrombus removal comes with additional upfront costs derived from devices, imaging and critical care bed usage. However, significant potential savings from reduction in PTS and rethrombosis rates may reduce overall societal costs. This review focuses on iliofemoral thrombosis, however, the less commonly encountered but clinically important subclavian vein thrombosis is also discussed.

Primary subclavian vein thrombosis and its long-term effect on quality of life

We aimed to compare the long-term results of three different strategies for treatment of patients with primary (spontaneous or effort related) subclavian vein thrombosis (PSVT). We followed 45 consecutive patients who had been treated for PSVT receiving either oral anticoagulant therapy only ( n = 14, group 1); thrombolysis followed by anticoagulant therapy ( n = 14, group 2); or thrombolysis, transaxillary first rib resection and anticoagulant therapy ( n = 17, group 3). Endpoints were persisting symptoms and quality of life (QoL). The latter was assessed with the EuroQol (EQ-5D) questionnaire at the end of follow-up. The design is a case-control study with three different groups. Predictors for residual symptoms and QoL were analyzed with logistic and linear regression analysis. Patients in groups 2 and 3 had significantly less pain, swelling and fatigue in the afflicted limb at six weeks. There was no difference in pain ( P = 0.90), swelling ( P = 0.58), fatigue ( P = 0.61), functional impairment ( P = 0.61), recurrence ( P = 0.10) or QoL ( P = 0.25) between groups at the end of follow-up (mean follow-up 57 months [range 2–176, SD ± 46]). Treatment strategy was not predictive of QoL ( P = 0.91, analysis of variance). No differences in long-term symptoms or QoL between patients with successful and unsuccessful thrombolysis were present. In conclusion, thrombolysis with or without first rib resection does not appear to contribute to lasting symptom reduction and improvement of QoL in this study. The effect of thrombolysis may be limited to short-term symptom relief. Transaxillary first rib resection was not associated with improved late outcome (symptoms, QoL) and did not reduce recurrence rate.

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.

Upper limb deep vein thrombosis: a literature review to streamline the protocol for management

OBJECTIVE

The objective of this article is to provide up-to-date information about aetiology, pathogenesis, diagnostic modalities and treatment of upper limb deep vein thrombosis (ULDVT).

METHODS

Generic terms including ULDVT, axillary-subclavian DVT, and complications of central venous catheters were searched on electronic database. We analysed original studies, review articles and evaluation studies published over the last 25 years.

RESULTS

Forty-seven studies on ULDVT encompassing 2,557 patients were evaluated. The incidence of ULDVT was quoted 1-4% of the total DVT. Primary ULDVT (20% of the total) was due to activity-related venous trauma. Secondary ULDVT (80% of the total) was due to central venous catheters and malignancy. Duplex ultrasound (sensitivity 78-100% and specificity 82-100%), contrast venography (gold standard) and magnetic resonance venography were the diagnostic tools used. Pulmonary embolism (2-35%) and post-thrombotic syndrome (7-46%) were the main sequelae. Anticoagulation was the universal intervention, giving 79% symptom relief (13.2% rethrombosis rate). Thrombolysis and/or percutaneous thrombectomy were used in 38% of cases for the management of ULDVT, giving 83% symptom relief (90% recanalization rate and 9% rethrombosis rate). Surgical decompression, venous angioplasty and superior vena cava filters were the main adjunctive interventions.

CONCLUSION

ULDVT, although rare, is associated with considerable morbidity and mortality (29-40%) due to potential risks of pulmonary embolism, post-thrombotic syndrome and loss of vascular access. Simple anticoagulation is suitable for the majority of patients. Thrombolysis/thrombectomy is often successful but less frequently used. Surgical decompression, venous angioplasty and superior vena cava filters have some role in recurrent cases. An optimal management protocol can be established using a multimodality approach.

Paget-Schroetter syndrome treated with thrombolytics and immediate surgery

INTRODUCTION

Reviewed are the results of the emergent treatment of effort thrombosis of the subclavian vein. The protocol calls for immediate thrombolysis, followed by surgery at the time of the acute event. The one-stage procedure includes decompression of the thoracic inlet by subclavicular removal of the first rib, subclavius muscle, scalenectomy, and vein patch plasty of the stenotic segment of the vein.

METHODS

Between July 1985 through June 2006, 114 patients presented with Paget-Schroetter syndrome (effort thrombosis of the subclavian vein), 97 of which (group I) were seen < or =2 weeks of onset of symptoms. They underwent an emergent protocol treatment in which thrombolysis is immediately followed by surgery at the time of the acute event. In addition, another 17 patients (group II) were referred to our institution after being treated elsewhere with initial thrombolysis, but with surgery deferred a mean 34 days (range, 2 weeks to 3 months) after the initial event. All patients underwent the same lytic and surgical protocol. Operability was determined by the findings on the venogram. Routine postoperative anticoagulation for 8 weeks was implemented with warfarin and clopidogrel.

RESULTS

There was 100% success in re-establishing the flow and normal caliber of the subclavian vein in the 97 patients in group I. Seven patients showed some residual stenosis that required balloon plasty and implant of a stent. Postoperative duplex ultrasound imaging documented patency in all 97 patients (100%). The 17 patients with delayed surgery (group II) showed progression of the fibrosis, with vein obstruction in 12 (70%). Only five patients (29%) were operable with successful results. The remaining 12 patients were inoperable owing to extensive fibrosis and occlusion of the inflow, and all 12 have remained disabled for the use of their arm.

CONCLUSIONS

The emergent approach to treat Paget-Schroetter syndrome seems to render the optimal results, with 100% effectiveness in re-establishing venous flow and normal caliber to the vessel. When properly conducted, this operation avoids the use of stents or balloon plasty with excellent long-term results, leaving the patients unrestricted for physical activities.

Effort thrombosis (Paget-Schroetter syndrome) in active young adults: Current concepts in diagnosis and treatment

Effort thrombosis or Paget-Schroetter syndrome most often affects young, active adults who are engaged in sports activities or whose professions require repetitive arm movements causing trauma to the axillary-subclavian vein and precipitating deep vein thrombosis. The presence of unilateral edema in the upper extremity is often thought to be attributable to trauma from an exercise regimen rather than acute deep vein thrombosis or compression of the subclavian vein by extrinsic anatomic structures. Because this syndrome occurs in young, active adults it has the potential for considerable long-term morbidity if it remains undetected or inadequately treated. Inadequate or inappropriate treatment may cause a loss of productivity over a lifetime and significantly affect the quality of life. Although more prevalent in male athletes, it is now increasingly affecting young women as they become more seriously involved in athletic endeavors. The purpose of this article is to increase the awareness of the prevalence, clinical significance, and importance of early detection of effort thrombosis of the axillary-subclavian vein, also known as Paget Schroetter syndrome, to educate health care providers regarding the limitations of some diagnostic tools, and to introduce new methods of treatment that offer better long-term results. The prevalence, differential diagnosis, diagnostic modalities, and medical and surgical interventions that have been successfully used to treat Paget-Schroetter syndrome are discussed, and evidence is provided to support the selections. The results of patients who were identified and treated within the last 2 years at the University of Southern California Center for Vascular Care are reviewed.

The Importance of Thrombophilia in the Treatment of Paget-Schroetter Syndrome

Venous thoracic outlet syndrome (V-TOS) and associated subclavian vein thrombosis (SVT) result in significant patient morbidity and can be difficult to manage. Previous studies have suggested that both mechanical compressive factors and pathological alterations in patient coagulation may contribute to the development of SVT; however, no study has specifically evaluated the role of thrombophilia in the treatment of V-TOS and the need for long-term anticoagulation as an adjunct to surgical decompression. This retrospective study describes the clinical courses of 18 patients treated for V-TOS with and without acute SVT. In this review, 67% of patients with SVT are found to have relatively common coagulation disorders and 90% of postoperative complications were associated with some form of thrombophilia. This study suggests that thrombophilia may play an important role in the pathogenesis of V-TOS and may be a determinant of the success of surgical decompression. Clotting disorders should therefore be aggressively evaluated in this patient population and can improve therapeutic outcome.

Life-threatening acute and chronic thromboembolic pulmonary hypertension and subclavian vein thrombosis

Severe thromboembolic pulmonary hypertension is an infrequent but potentially fatal complication of effort thrombosis (Paget-Schroetter syndrome) of the upper extremity. It has been sporadically reported in the literature, but in most cases has affected young, otherwise healthy athletes. Because this syndrome has been rarely described, it is likely underdiagnosed, and optimal evaluation and treatment has not been established. We describe three young athletic persons who developed thrombosis of the subclavian vein after repetitive motion of the upper extremity, and in whom life-threatening pulmonary hypertension resulted from acute and chronic pulmonary emboli. We then review the mechanism, clinical presentation, diagnosis, and available therapeutic modalities.

Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome

BACKGROUND

The purpose of this study was to determine the clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with nonoperative management of patients with primary subclavian vein thrombosis.

METHODS

Sixty-four patients treated for Paget-Schroetter syndrome from 1996 to 2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First-rib resection was performed in 29 patients (45%) within the first 3 months, with a success rate of 93%. The remaining 35 patients (55%) were treated nonoperatively and constitute this study's population.

RESULTS

Of the 35 patients with successful nonoperative management, 8 (23%) developed recurrent thrombotic events of the same extremity at a mean follow-up time of 13 months after thrombolysis (range, 6-33 months). These eight patients subsequently underwent first-rib resection with a 100% success rate without further sequelae at a mean follow-up time of 51 months (range, 2-103 months). The other 27 patients remained symptom free at a mean follow-up interval of 55 months (range, 10-110 months). Bivariate analyses determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P = .05). The recurrence group was also significantly younger than the asymptomatic group (22 vs 36 years; P = .01). Sex, being a competitive athlete, a history of trauma, whether the dominant arm was affected, time of delay to lysis, initial clot burden, response to original lysis, use of adjunctive balloons or mechanical thrombectomy devices, residual stenosis on venography, length of time on warfarin, and patency of the vein on follow-up duplex examination were all characteristics not associated with long-term recurrence after nonoperative management.

CONCLUSIONS

Conservative nonoperative management of primary subclavian vein thrombosis can be successfully used with acceptable long-term results. A younger age (<28 years old) and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.

Exercise-induced deep vein thrombosis of the upper extremity. 1. Literature review

Paget-Schroetter syndrome or effort-related upper extremity deep vein thrombosis is a rare condition that usually afflicts young healthy individuals, most commonly males. The cause is multifactorial but almost always involves extrinsic compression of the subclavian vein at the thoracic inlet, causing venous stenosis from repetitive trauma. The diagnosis of this condition may be difficult, and its delay may contribute to potential complications including thrombosis progression, pulmonary embolism, thrombosis recurrence, and post-thrombotic syndrome. Similarly, the best therapeutic option has not been established and in the lack of evidence-based guidelines, treatment may be extremely challenging especially in children, in whom long-term complications can be particularly disabling.

Effort-induced venous thrombosis of the upper limbs

OBJECTIVE

To report 3 patients who presented with effort-induced thrombosis of the upper limbs.

CASE PRESENTATIONS AND INTERVENTION

The 1st patient presented with a 2-week history of fever, shortness of breath, and increasing swelling of the neck after strenuous manual work. The 2nd patient presented with a 2-day history of pain, swelling, and discolouration of the right upper limb following a session of intense weight lifting. The 3rd patient presented with a 2-day history of swelling, pain, and discolouration of the left upper limb due to repeated rotatory movements of the arm at work. In all 3 cases, the diagnosis of effort-induced thrombosis of subclavian and axillary veins was made. In the 1st case, the lesion was bilateral and complicated by superior vena cava obstruction. In the 2nd and in the 3rd case, right and left subclavian veins were thrombosed, respectively. After consulting the vascular team, anticoagulation therapy was initiated in all 3 cases. The patients described showed gradual recovery with eventual recanalization of the thrombosed veins on follow-up.

CONCLUSIONS

These cases indicate the need to consider thrombosis of the subclavian vein as a part of the differential diagnosis in a patient with a history of strenuous manual work. Therapeutic options include immediate anticoagulation or thrombolysis, while vascular surgery should remain an option for cases with underlying anatomical anomalies.

Thrombolytic Therapy: Current Clinical Practice

Thrombolytic therapy is an essential tool in the array of therapies designed to reopen arteries and veins occluded with thrombus. As the use of thrombolytic agents has entered mainstream practice, their application has expanded to include a wide variety of indications and settings. Thrombolytic agents are used in patients who have thrombosis of coronary arteries, precerebral and cerebral arteries, the aorta, iliac and mesenteric arteries, and peripheral arteries. The use of thrombolysis in venous thrombosis has included deep venous thrombosis of the upper and lower extremities and vena cava, mesenteric veins, cerebral veins, and central access catheters. Guidelines are available from the American College of Cardiology/American Heart Association regarding thrombolysis in myocardial infarction and from the American Stroke Association regarding thrombolysis in acute ischemic stroke.

Upper extremity deep venous thrombosis: interventional management

Upper extremity deep venous thrombosis, previously thought to be a relatively innocuous disorder in comparison to lower extremity deep venous thrombosis, has recently begun to receive the attention it merits. Its optimal management remains controversial despite the development of several new techniques and devices which allow more rapid removal of thrombus and treatment of underlying venous stenotic disease. The following article provides a framework to discuss its treatment, with the emphasis on endovascular management.

Paget-Schroëtter syndrome: what to do?

Paget-Schroëtter syndrome, or primary thrombotic occlusion of the axillary-subclavian vein, is diagnosed in a 42-year-old man subsequently treated with thrombolysis and anticoagulation. Treatment strategies, including early and delayed surgical options, are discussed to determine the best risk/benefit ratio.

Arterial and venous injuries in athletes: findings and their effect on diagnosis and treatment

Athletes are susceptible to a variety of vascular injuries, yet clinical presentation may be subtle and the extent of injury underestimated.

OBJECTIVE

To evaluate Stanford University's experience with the diagnosis and management of vascular injuries incurred during athletic competition.

METHODS

Between June 1994 and June 2001, 29 patients with athletic competition-related vascular injuries were treated by our service. Clinical presentation, type of athletic competition, location of injury, type of therapy, and degree of rehabilitation were analyzed.

RESULTS

Mean patient age was 23.8 years. In total, 17 arterial and 12 venous injuries were treated. Arterial injuries consisted of 8 axillary or subclavian branch artery aneurysms with embolization, 6 popliteal artery injuries, and 3 external iliac artery injuries. Subclavian vein thrombosis (SVT) accounted for all venous complications. Sixteen (94%) patients with arterial injuries required surgical repair. Fifteen reconstructions maintained primary patency with a mean follow-up of 43.9 months. All patients with SVT received lytic therapy and anticoagulation. Eight of these (67%) required thoracic outlet decompression and venolysis. All patients with SVT have remained stable without further venous thrombosis.

CONCLUSION

Athletes are susceptible to vascular injuries that may not be easily recognized. However, a high index of suspicion, appropriate imaging, and prompt treatment allow athletes to return to competition in most cases.

Thrombolytic therapy: clinical applications

The therapeutic use of thrombolytic agents is the result of the increasing understanding of the pathophysiologic mechanisms underlying normal and deranged thrombosis and fibrinolysis. Plasminogen activators capable of increasing the production of plasmin exhibit considerable efficacy in the treatment of a variety of arterial and venous thrombotic disorders. The ideal thrombolytic agent has not been developed, but the desired clinical result of rapid opening of the thrombosed vessel without reocclusion, without activation of systemic fibrinogenolysis, and without a risk of hemorrhage are defined. Clinical studies clearly demonstrate that the addition of a variety of adjunctive agents to available thrombolytics enhances benefit without inordinate risk. The addition of intravascular angioplasty and stenting to thrombolysis increases the potential long-term benefit. Newer thrombolytic agents and new protocols for the use of existing therapies offer the promise of saving many who would otherwise succumb to coronary or cerebral arterial thrombosis or to venous thromboembolism.