Paget-Schroetter syndrome treated with thrombolytics and immediate surgery

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.