Effort subclavian vein thrombosis: evolution of management

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.

Minimally invasive treatments for venous compression syndromes

The management of venous compression syndromes has historically been reliant on surgical treatment when conservative measures fail. There are, however, several settings in which endovascular therapy can play a significant role as an adjunct or even a replacement to more invasive surgical methods. We explore the role of minimally invasive treatment options for three of the most well-studied venous compression syndromes. The clinical aspects and pathophysiology of Paget-Schroetter syndrome (PSS), nutcracker syndrome, and May-Thurner syndrome are discussed in detail, with particular emphasis on the role that interventionalists can play in minimally invasive treatment.

Effort thrombosis (Paget-Schroetter syndrome) in a 16-year-old male

Patient: Male, 16

Final Diagnosis: Effort thrombosis (Paget-Schroetter Sydnrome)

Symptoms: Swollen arms

Medication: —

Clinical Procedure: —

Specialty: Metabolic Disorders and Diabetics

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.

Endoluminal treatment for venous vascular complications of malignant tumors

The aim of this study was to explore the efficacy and safety of interventional treatment for venous vascular complications of malignant tumors. Sixty-one patients with venous vascular complications of malignant tumors were treated from May 2002 to May 2009; 37 men and 24 women with mean age 57.8 years (33-82 years). Lesions included acute deep vein thrombosis (n=18); venous stenosis or occlusion (n=32); tumor embolus in vein (n=11). The interventional therapeutic operations included vena cava filter implantation, trans-catheter thrombolytic therapy, recanalization, percutaneous transluminal angioplasty (PTA) and stenting. The success rate of thrombolysis and stent implantation, the clinical success rate, complications, recurrence rate of the treated region and survival duration were recorded. Eighteen patients accepted filter and thrombolytic therapy with a success rate of 100%; total urokinase dosage was 7.42±1.49 (4.5-10) million units. Symptoms disappeared (n=15), were palliated (n=3) and thrombi were completely dissolved (n=2), almost completely dissolved (n=8, >90%), partially dissolved (n=6, 50-90%) and not dissolved (n=2, <50%). No pulmonary embolism emerged after the operation. Forty-three patients accepted recanalization, PTA and stent therapy with a success rate of 95.3% (41/43). Symptoms disappeared (n=25), were palliated (n=16) and did not change (n=2) 3 days following the operation. There were no severe complications during the procedure. During follow-up, 12 patients again suffered symptoms of venous occlusion and 47 patients died of tumor aggravation without symptom recurrence. As a result, interventional therapy has advantages including smaller injuries, well tolerance, high success rate, quick palliation of symptoms and superior clinical efficacy in the treatment of venous vascular complications for malignant tumors.

Subclavian vein thrombosis: an unusual presentation of renal cell carcinoma

Subclavian vein thrombosis is an uncommon clinical condition which is often associated with venous catheterization or secondary to excessive effort. We present a 54-year-old female with subclavian vein thrombosis as a first presentation of renal cell carcinoma. Although this is an unusual presentation, malignancy should be considered in the differential diagnosis. Hypercoagulability as part of a paraneoplastic syndrome was considered a possible etiology. In patients with otherwise unexplained subclavian vein thrombosis, full systemic examination and radiological evaluation of the abdomen, retroperitoneum and pelvis should be pursued. A review of the literature relevant to this unusual case is provided.

Unique treatment regimen for effort thrombosis in the nondominant extremity of an overhead athlete: a case report

OBJECTIVE

To advise athletic trainers on the potential for effort thrombosis to occur in nonthrowing athletes and to underscore the importance of early recognition and treatment.

BACKGROUND

An 18-year-old offensive lineman presented with a 1-day history of diffuse shoulder pain with no specific history of injury; swelling and erythema involved the entire left upper extremity. He was immediately referred to the team physician, who suspected deep vein thrombosis and sent the athlete to an imaging center. Duplex ultrasound was obtained on the day of presentation, and he was admitted to the hospital that evening.

DIFFERENTIAL DIAGNOSIS

Deep vein thrombosis, thoracic outlet syndrome, shoulder tendinitis.

TREATMENT

Anticoagulation with heparin was administered at the hospital, and he was sent home the next day on subcutaneous enoxaparin sodium, followed by a 5-mg daily dose of oral warfarin sodium. Oral anticoagulants were continued for a total of 4 weeks. The athlete began upper body lifting and was released 5 weeks postinjury to gradually return to football without restrictions.

UNIQUENESS

Effort thrombosis is typically seen in the dominant arm of athletes, and the current treatment protocol calls for thrombolysis or surgical intervention. This athlete, whose position required repeated elevation of his arms in forward flexion, sustained the injury in his nondominant arm, was treated with anticoagulation only, and had a full return to football. At 18-month follow-up, he had no recurrence of symptoms.

CONCLUSIONS

Early recognition and treatment of athletes with effort thrombosis is paramount to a successful clinical outcome and prompt return to play.

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.

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.