Subclavian Vein Thrombosis Paget-Schroetter Syndrome

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. 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. 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. 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.

Paget-Schroetter syndrome is a serious condition that if not treated promptly and properly leads to severe sequelae and permanent disability. In its late stage, chronic fibrous obliteration of the vein is rarely amenable to surgical treatment, except in very few select cases. We treated 126 Paget-Schroetter syndrome patients (group I) by implementing an emergency protocol of thrombolysis by catheter-directed infusion, followed by immediate surgery through an anterior subclavian approach entailing (1) decompression of the thoracic inlet and (2) repairing the vein with a vein patch to reestablish its normal caliber. In addition, we treated another selective group of 81 patients (group II) for chronic fibrotic obstruction several months after their original event, but only when the inflow was adequate. Our acute emergency care resulted in a 100% long-term patency rate in group I, with no sequelae. The patency rate in group II was 100% as well, but in 74% a long vein patch, endovascular stents, or homograft implants were used. Implementation of an emergency approach to treat Paget-Schroetter syndrome is highly recommended to prevent the delayed sequelae of permanent subclavian vein obliteration and disability. In chronic obstruction, when feasible, we recommend a long saphenous vein patch, followed by endovascular stent implant.

A new technique extending the incision used for thoracic outlet decompression with a subclavicular approach to the first rib is presented. After the first rib and scalenotomy are removed, the subclavicular incision is continued into the sternum medially and superiorly to the sternal notch. This gives easy access to the innominate-subclavian-axillary vein segment. Eight patients with extensive chronic fibrotic obstruction of the subclavian-innominate vein segment underwent operation with this technique. It allows placement of either long patches of saphenous vein to reestablish normal caliber or replacement, as is our choice, with a small-sized cryopreserved descending thoracic aortic homograft. The operation is carried out in an extrapleural plane preserving the sternoclavicular joint, avoiding the deformity caused by transclavicular techniques. Repair of the sternotomy creates a stable incision. Follow-up to 14 months shows patency of the venous channel with no complications. This surgical approach is recommended to solve the problem of satisfactory exposure of the subclavian-innominate venous channel after decompression of the thoracic outlet.