Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget-Schroetter Syndrome

Abstract

Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome [PSS]) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT), followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer on the basis of response. The aim of this study was to evaluate outcomes of this flexible protocol. Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. End points included success of TL and eventual clinical outcome. Patients were divided into two groups: group I, TL/PMT + TOD; and group II, medical management/anticoagulation + TOD. PSS was diagnosed in 103 patients; 97 (42 male, 55 female; mean age, 31 years) who underwent TOD were included in the study. Group I included 53 patients who underwent TOD after initial TL/PMT (30 at our institution and 23 elsewhere), with success (acute thrombus resolution) in 93% (n = 28) and 69% (n = 16), respectively. Adjunctive balloon catheter venoplasty was performed in 66%. TL failed to recanalize the occluded SCV in 16% (n = 9). Complete thrombus resolution was seen in 7% (n = 4). Residual chronic thrombus in 61% (n = 33) resulted in median SCV stenosis of 50% (range, 10%-80%). With continued anticoagulation, further thrombus retraction was noted with mean 30% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range, 2-240 days). Rethrombosis of the SCV occurred in three patients 1 to 3 days postoperatively and was managed with mechanical thrombectomy, SCV stenting, balloon angioplasty, and anticoagulation. Symptomatic relief was achieved in 46 of 53 (85%) patients at a median follow-up of 14 months. Group II included 44 patients who underwent TOD after medical treatment elsewhere with anticoagulation alone for an average of 6 months (range, 2-18 months), with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (88%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in seven patients (16%); the indication for TOD was residual symptoms from compression of collateral veins. In the remaining 37 patients, mean residual stenosis of 56% (range, 30%-80%) was noted in the SCV. TOD was performed at a median of 257 days after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in three patients and stenting in two. Symptomatic relief was achieved in 39 of 44 (88%) at a median follow-up of 24 months. For PSS, a management protocol encompassing elective TOD at a convenient time after TL is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the SCV and may reduce the need for open venous reconstruction.