Download PDF
Semin intervent Radiol 2012; 29(01): 044-051
DOI: 10.1055/s-0032-1302451
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Comprehensive Management of Subclavian Vein Effort Thrombosis

Robert W. Thompson
1   The Center for Thoracic Outlet Syndrome and the Department of Surgery, Section of Vascular Surgery
2   Radiology, Washington University School of Medicine, St. Louis, Missouri
› Author Affiliations
Further Information

Publication History

Publication Date:
16 April 2012 (online)

Also available at
   Permissions and Reprints

Abstract

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.

Keywords

upper extremity venous thrombosis - axillary-subclavian vein - thoracic outlet syndrome - thrombolysis - first rib - surgical treatment
 

  • References

  • 1 Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010; 51 (6) 1538-1547
    CrossrefPubMedGoogle Scholar
  • 2 Melby SJ, Vedantham S, Narra VR , et al. Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome). J Vasc Surg 2008; 47 (4) 809-820; discussion 821
    CrossrefPubMedGoogle Scholar
  • 3 Sanders RJ, Hammond SL. Venous thoracic outlet syndrome. Hand Clin 2004; 20 (1) 113-118, viii
    CrossrefPubMedGoogle Scholar
  • 4 Cassada DC, Lipscomb AL, Stevens SL, Freeman MB, Grandas OH, Goldman MH. The importance of thrombophilia in the treatment of Paget-Schroetter syndrome. Ann Vasc Surg 2006; 20 (5) 596-601
    CrossrefPubMedGoogle Scholar
  • 5 Rutherford RB. Primary subclavian-axillary vein thrombosis: the relative roles of thrombolysis, percutaneous angioplasty, stents, and surgery. Semin Vasc Surg 1998; 11 (2) 91-95
    PubMedGoogle Scholar
  • 6 Schneider DB, Curry TK, Eichler CM, Messina LM, Gordon RL, Kerlan RK. Percutaneous mechanical thrombectomy for the management of venous thoracic outlet syndrome. J Endovasc Ther 2003; 10 (2) 336-340
    CrossrefPubMedGoogle Scholar
  • 7 Urschel Jr HC, Patel AN. Paget-Schroetter syndrome therapy: failure of intravenous stents. Ann Thorac Surg 2003; 75 (6) 1693-1696; discussion 1696
    CrossrefPubMedGoogle Scholar
  • 8 Adams JT, McEvoy RK, DeWeese JA. Primary deep venous thrombosis of the upper extremity. Arch Surg 1965; 91: 29-42
    CrossrefPubMedGoogle Scholar
  • 9 Tilney ML, Griffiths HJG, Edwards EA. Natural history of major venous thrombosis of the upper extremity. Arch Surg 1970; 101 (6) 792-796
    CrossrefPubMedGoogle Scholar
  • 10 Donayre CE, White GH, Mehringer SM, Wilson SE. Pathogenesis determines late morbidity of axillosubclavian vein thrombosis. Am J Surg 1986; 152 (2) 179-184
    CrossrefPubMedGoogle Scholar
  • 11 Gloviczki P, Kazmier FJ, Hollier LH. Axillary-subclavian venous occlusion: the morbidity of a nonlethal disease. J Vasc Surg 1986; 4 (4) 333-337
    CrossrefPubMedGoogle Scholar
  • 12 Lindblad B, Tengborn L, Bergqvist D. Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg 1988; 2 (3) 161-165
    CrossrefPubMedGoogle Scholar
  • 13 Aziz S, Straehley CJ, Whelan Jr TJ. Effort-related axillosubclavian vein thrombosis. A new theory of pathogenesis and a plea for direct surgical intervention. Am J Surg 1986; 152 (1) 57-61
    CrossrefPubMedGoogle Scholar
  • 14 Kunkel JM, Machleder HI. Spontaneous subclavian vein thrombosis: a successful combined approach of local thrombolytic therapy followed by first rib resection. Surgery 1989; 106 (1) 114
    PubMedGoogle Scholar
  • 15 Kunkel JM, Machleder HI. Treatment of Paget-Schroetter syndrome. A staged, multidisciplinary approach. Arch Surg 1989; 124 (10) 1153-1157; discussion 1157–1158
    CrossrefPubMedGoogle Scholar
  • 16 Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg 1993; 17 (2) 305-315; discussion 316–317
    PubMedGoogle Scholar
  • 17 Lee WA, Hill BB, Harris Jr EJ, Semba CP, Olcott C IV. Surgical intervention is not required for all patients with subclavian vein thrombosis. J Vasc Surg 2000; 32 (1) 57-67
    CrossrefPubMedGoogle Scholar
  • 18 Lee JT, Karwowski JK, Harris EJ, Haukoos JS, Olcott IV C. Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg 2006; 43 (6) 1236-1243
    CrossrefPubMedGoogle Scholar
  • 19 Urschel Jr HC, Razzuk MA. Improved management of the Paget-Schroetter syndrome secondary to thoracic outlet compression. Ann Thorac Surg 1991; 52 (6) 1217-1221
    CrossrefPubMedGoogle Scholar
  • 20 Angle N, Gelabert HA, Farooq MM , et al. Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg 2001; 15 (1) 37-42
    CrossrefPubMedGoogle Scholar
  • 21 Caparrelli DJ, Freischlag J. A unified approach to axillosubclavian venous thrombosis in a single hospital admission. Semin Vasc Surg 2005; 18 (3) 153-157
    CrossrefPubMedGoogle Scholar
  • 22 Thompson RW, Schneider PA, Nelken NA, Skioldebrand CG, Stoney RJ. Circumferential venolysis and paraclavicular thoracic outlet decompression for “effort thrombosis” of the subclavian vein. J Vasc Surg 1992; 16 (5) 723-732
    PubMedGoogle Scholar
  • 23 Molina JE. Surgery for effort thrombosis of the subclavian vein. J Thorac Cardiovasc Surg 1992; 103 (2) 341-346
    PubMedGoogle Scholar
  • 24 Molina JE. Need for emergency treatment in subclavian vein effort thrombosis. J Am Coll Surg 1995; 181 (5) 414-420
    PubMedGoogle Scholar
  • 25 Azakie A, McElhinney DB, Thompson RW, Raven RB, Messina LM, Stoney RJ. Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression. J Vasc Surg 1998; 28 (5) 777-786
    CrossrefPubMedGoogle Scholar
  • 26 Molina JE, Hunter DW, Dietz CA. Paget-Schroetter syndrome treated with thrombolytics and immediate surgery. J Vasc Surg 2007; 45 (2) 328-334
    CrossrefPubMedGoogle Scholar
  • 27 Melby SJ, Thompson RW. Supraclavicular (paraclavicular) approach for thoracic outlet syndrome. In: Pearce WH, Matsumura JS, Yao JST, eds. Operative Vascular Surgery in the Endovascular Era. Evanston, IL: Greenwood Academic; 2008: 434-445
    Google Scholar
  • 28 Pin RH, DeLeon R, Freischlag JA. Axillary approach for thoracic outlet syndrome. In: Pearce WH, Matsumura JS, Yao JST, eds. Vascular Surgery in the Endovascular Era. Evanston, IL: Greenwood Academic; 2008: 429-433
    Google Scholar
  • 29 Urschel Jr HC, Razzuk MA. Paget-Schroetter syndrome: what is the best management?. Ann Thorac Surg 2000; 69 (6) 1663-1668; discussion 1668–1669
    CrossrefPubMedGoogle Scholar
  • 30 de León R, Chang DC, Busse C, Call D, Freischlag JA. First rib resection and scalenectomy for chronically occluded subclavian veins: what does it really do?. Ann Vasc Surg 2008; 22 (3) 395-401
    CrossrefPubMedGoogle Scholar
  • 31 Thompson RW, Petrinec D. Surgical treatment of thoracic outlet compression syndromes: diagnostic considerations and transaxillary first rib resection. Ann Vasc Surg 1997; 11 (3) 315-323
    CrossrefPubMedGoogle Scholar
  • 32 Thompson RW, Petrinec D, Toursarkissian B. Surgical treatment of thoracic outlet compression syndromes. II. Supraclavicular exploration and vascular reconstruction. Ann Vasc Surg 1997; 11 (4) 442-451
    CrossrefPubMedGoogle Scholar