surgical and endovascular treatment of paget-schroetter

Image from http://www.nlm.nih.gov/medlineplus/ency/imagepages/8963.htm

INTRODUCTION

Image from http://www.nlm.nih.gov/medlineplus/ency/imagepages/8963.htm

Anterior scalene muscle

Subclavius muscle

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

Anterior scalene muscle

Subclavius muscle

Pinch of the vein in arm abduction

2 / 100.000 per year

1-4% of all DVT

INCIDENCE

Lindblad B et al. DVT of the axillary-subclavian veins: epidemiologic data, treatment and late sequelae. Eur J Vasc Surg 1988; 2:161-5

Mean age early 30s

Male to Female ratio 2:1

Right Arm (dominant) 80%

Vigorous exercise 60-80%

EPIDEMIOLOGY

Illig KA and Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010;51:1538-47

Blue, swollen, painful upper extremity

Edema + dilated superficial veins in arm, neck, chest

Pulmonary embolism 6-15%

NATURAL HISTORY: CLINICAL PRESENTATION

Adams JT and DeWeese JA. Effort thrombosis of the axillary and subclavian veins. J Trauma 1971;11:923-30

Incidence 15-46%

PTS more severe in dominant arm

Good /excellent quality of life 29%

NATURAL HISTORY: POST-THROMBOTIC SYNDROME

Elman EE et al. The posthrombotic syndrome after upper extremity DVT: a systematic review. Thrombosis Research2006;117:609-614

Persistent pain / heaviness /cramps

Persistent swelling and edema

Venous dilatation

Functional disability of the arm

Impaired quality of life

NATURAL HISTORY: POST-THROMBOTIC SYNDROME

Elman EE et al. The posthrombotic syndrome after upper extremity DVT: a systematic review. Thrombosis Research2006;117:609-614

Symptoms of chronic venous obstruction 78%

Moderate-severe 30%

NATURAL HISTORY: POST-THROMBOTIC SYNDROME

Persson LM et al. Hemodynamic and morphologic evaluation of sequelae of primary upper extremity DVT. J Vasc Surg2006;43:1230-5

Anticoagulation alone

Thrombolytic therapy

Decompression of thoracic outlet

TREATMENT: CONTROVERSIES

2000-2011 22 patients

14 women / 9 men

Medium age 32 years

Onset of symptoms 3,2 days (SD 7,2)

Sports/Risk profession 72,7%

TREATMENT

Thrombolityc therapy with urokinase 100.000 U / h

Reimaging 12-hour interval

Mean lysis time 51,2 hours (24-96 h)

Succesful lysis in 100%

TREATMENT

Endovascular intervention

Thrombolysis alone 75%

Thrombolysis + venoplasty 21%

Thrombolysis + stenting 4%

Transaxillary first rib resection 100%

TREATMENT

Pneumothorax 4,3%

Horner 4,3%

COMPLICATIONS

Clinic / Ecodoppler / QuickDASH survey

Mean 54 months

Re-thrombosis 0%

Restenosis 8,7%

Permeability (1, 5 years) 100%

Stent fracture 4,3%

FOLLOW UP

FOLLOW UP

QuickDASH (0-100)

Mean 12,5 points (SD 23,1)

Preop 14,9 (SD 18,3) Postop 14,8 (SD 15,5)*

FOLLOW UP: QUALITY OF LIFE

http://www.orthopaedicscore.com/scorepages/disabilities_of_arm_shoulder_hand_score_quickdash.html

* Cordobes J, Lozano P Functional recovery after surgery for TOS. Eur J Vasc Endovasc Surg 2008;35:79-83

CONCLUSIONS

Low complication rate

Satisfactory long-term outcomes

Good quality of life