Original article
General thoracic
Surgery Remains the Most Effective Treatment for Paget-Schroetter Syndrome: 50 Years' Experience

Presented at the Fifty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 7–10, 2007.
https://doi.org/10.1016/j.athoracsur.2008.03.021Get rights and content

Background

Significant improvements were made in the diagnosis and management of Paget-Schroetter syndrome (thrombosis of the axillary–subclavian vein) secondary to thoracic outlet syndrome during the past 50 years. The diagnosis has often been extremely difficult.

Methods

Multiple approaches both in diagnosis and therapy have been tried during the years. After recognizing that the underlying pathologic process resulted from an abnormal insertion of the costoclavicular ligament laterally on the first rib, along with hypertrophy of the scalenus anticus muscle, 506 of 626 extremities have been managed by thrombolytic therapy followed by prompt transaxillary resection of the first rib. These patients have been followed up from 1 to 32 years (average of 7.2 years ± 1.0 standard deviation).

Results

Four hundred eighty-six patients (96%) improved. Because the pathophysiology is not well understood, many venograms suggest intraluminal disease rather than external compression. Therefore, attempts at opening the narrowed vein with intraarterial techniques do not work. Use of percutaneous venous angioplasty with stents have all occluded in our experience, making further management difficult. Venous bypass grafts fail because of low venous pressure.

Conclusions

Recognition that an abnormal congenital lateral insertion of the costoclavicular ligament on the first rib causes venous occlusion in Paget-Schroetter syndrome has led to acute thrombolysis, followed by prompt first rib resection, as the ideal management.

Section snippets

Material and Methods

The chair of the institutional review board of the Baylor Research Institute reviewed the study and determined that it was exempt from institutional review board approval under 45 CFR 46.101 (b) (4).

Clinical manifestations of effort thrombosis of the axillary subclavian vein in the acute and subacute phases were evaluated in 626 extremities of 608 patients, 18 being bilateral. There were 307 women and 301 men, ranging in age from 16 to 51 years, with a mean of 32 years. (For the remainder of

Results

Results were evaluated as excellent, good, fair, or poor according to the criteria in Table 3 and are summarized in Table 4. In group I, 10 extremities of the 36 showed substantial improvement with anticoagulation and evaluation therapy. In 25 extremities, symptoms either were not completely improved or recurred. The pain, swelling, and dysfunction usually occurred when the patient returned to the job that had produced the difficulty initially.

Twenty-one of those required first rib resection,

Comment

Historically, Sir James Paget [2] in 1875 in London and Von-Schroetter [1] in 1884 in Vienna described this syndrome of thrombosis of the axillary-subclavian vein, which bears their names. The word effort [14] was added to thrombosis because of the frequent association with exertion superimposed on anatomic compressive elements in the thoracic outlet. Trauma, unusual occupations requiring repetitive muscular activity, as has been observed in professional athletes, linotype operators, painters,

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