Axillary-subclavian Vein Thrombosis Research Articles

Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome): Presented at the plenary session of the Forty-sixth Annual Meeting of the Midwestern Vascular Surgical Society, Grand Rapids, MI, September 15-17, 2022; E.R.D. was the recipient of the 2022 John F. Pheifer Best Venous Paper Award at the Forty-sixth Annual Meeting

Objective We assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS).

Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome)

ObjectiveWe assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS). MethodsWe performed a retrospective, single-center review of 266 patients who had undergone primary surgical treatment of VTOS between 2016 and 2022. The clinical outcomes were compared between the patients in four treatment groups determined by intraoperative venography. ResultsOf the 266 patients, 132 were male and 134 were female. All patients had a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range, 12-66 years). The timing of clinical presentation was acute (<15 days) for 132 patients (50%), subacute (15-90 days) for 71 (27%), and chronic (>90 days) for 63 patients (24%). Venography with catheter-directed thrombolysis or thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 patients (71%). The median interval between symptom onset and surgery was 78 days. After paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%). However, 26 (10%) had a long chronic AxSCV occlusion with axillary vein inflow insufficient for bypass reconstruction. Patch angioplasty was performed for focal AxSCV stenosis in 55 patients (21%) and bypass graft reconstruction for segmental AxSCV occlusion in 35 (13%). The patients who underwent external venolysis alone (patent or occluded AxSCV; n = 176) had a shorter mean operative time, shorter postoperative length of stay and fewer reoperations and late reinterventions compared with those who underwent AxSCV reconstruction (patch or bypass; n = 90), with no differences in the incidence of overall complications or 30-day readmissions. At a median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling, and only 17 (6%) were receiving anticoagulation treatment; 95% of those with a patent AxSCV at the end of surgery were free of arm swelling vs 69% of those with a long chronic AxSCV occlusion (P < .001). The patients who had undergone CDT at the initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery (30% vs 44%; P = .034) and 60% less likely to have arm swelling at follow-up (5% vs 13%; P < .05) vs those who had not undergone CDT. ConclusionsParaclavicular decompression, external venolysis, and selective AxSCV reconstruction determined by intraoperative venography findings can provide successful and durable treatment for >90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt usage of CDT, and even more effective surgical treatment.

Surgical Treatment Outcomes For Axillary-subclavian Vein Thrombosis Due To Venous Thoracic Outlet Syndrome

The objective of this study was to assess clinical presentation, operative findings, and surgical treatment outcomes for patients with axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS).

Upper Extremity Thrombosis Associated with Overactivity: A Comprehensive review article on Paget-Schroetter Syndrome

Paget–Schroetter disease, is a form of deep vein thrombosis (DVT) in upper extremity, in which bloodclots occurs in the deep veins of the arms. Paget–Schroetter disease syndrome is accounts for 30–40%of spontaneous axillary-subclavian vein thrombosis (ASVT) and for 10–20% of all upper extremity deepvenous thrombosis (UEDVT). Important predisposing factors for UEDVT include indwelling hardware,occult or overt malignancy and other thrombophilic states. Clinical manifestations include heaviness,cyanosis, redness, and dilated, visible veins across the upper arm and shoulder. It is diagnosed by compressionultrasonography with the help of colour Doppler. Thrombosis was managed conservatively with limbelevation and anticoagulation therapy. Hence, there is a need for increasing health workers awareness aboutrisk factors, etiology and the management of this unique and relatively uncommon disorder.

May-Thurner and Paget-Schroetter Syndromes: A Review.

May–Thurner and Paget–Schroetter syndromes are rare conditions encountered by vascular surgeons. An updated knowledge about these conditions is crucial for the effective management of patients with these syndromes who are mostly young.May–Thurner syndrome (MTS) is caused by the compression of the left common iliac vein by the right common iliac artery, and it is a risk factor for left leg deep venous thrombosis (DVT). Imaging (conventional venogram, computed tomography venography (CTV), magnetic resonance imaging (MRV)) can reveal the stenotic venous segment where the artery crosses. Stenting in symptomatic patients yields good results with minimal recurrence.Paget–Schroetter syndrome (PSS) is an idiopathic axillary-subclavian vein thrombosis mostly affecting the young population, particularly those who have repeated overhead arm activities. Narrower costoclavicular space along with other anatomical and coagulation factors can possibly lead to this condition. Patients can present with acute DVT, post-thrombotic syndrome or subclinical syndromes. Venogram, CTV or MRV with provocative maneuvres can confirm the dynamic obstruction. Thrombolysis followed by early bony decompression is advocated in patients presenting with acute arm DVT, as this approach is associated with limited residual disability and recurrence.This review discusses the current concepts and treatment options of both conditions.

Paget Schroetter Syndrome: upper extremity deep vein thrombosis after repetitive exercises

Axillary-subclavian vein thrombosis or Paget-Schroetter syndrome is an uncommon deep vein thrombosis usually caused by excessive and repetitive upper limb activity. It may cause post-trombotic syndrome, leading to a significant disability, unless treated early and properly. It is most often the consequence of a chronic compression of the subclavian vein at the level of the thoracic outlet. In this article, we present a 24-year-old male case with complaints of swelling, tightness, heaviness in the right half of his neck, upper arm, and right precordial area after repetitive exercises. No etiological factors such as trauma, venous catheter intervention, malignancy, hematologic disorder, or history of any chronic disease were described. Venous Doppler ultrasound revealed subclavian-axillary vein thrombosis. With early thrombolytic therapy, the symptoms relieved and venous patency was maintained.

A Case Report: A Young Waiter with Paget-Schroetter Syndrome

BackgroundPaget-Schroetter syndrome (PSS) is a rare presentation of primary axillary subclavian vein thrombosis that classically occurs in young men with a degree of underlying thoracic outlet syndrome after a period of upper extremity exertion. The primary complication of PSS is post-thrombotic syndrome, a result of chronic venous hypertension. ObjectivesTo educate Emergency Physicians on this condition to potentiate timely diagnosis and appropriate disposition. Case ReportA 29-year-old right-handed restaurant waiter presented with 3 days of non-painful, gradual-onset right upper extremity swelling with normal vital signs. The patient's history was otherwise notable for subjective fevers and a right forearm abrasion. Upon examination, the right upper extremity was neurovascularly intact and remarkable for uniform edema and erythema extending distally from the level of the mid-humerus. The primary differential diagnoses were deep venous thrombosis (DVT) vs. soft tissue infection. Venous phase contrast computed tomography did not reveal evidence of underlying soft tissue infection and was inconclusive regarding a DVT. Ultrasound demonstrated a right subclavian vein DVT. The patient was admitted and underwent thrombolysis, venolysis, and first rib resection and initiation of warfarin. ConclusionPSS is a rare presentation of upper-extremity DVT occurring classically in patients without commonly recognized pro-thrombotic risk factors. PSS carries the potential of significant morbidity in the form of post-thrombotic syndrome and pulmonary embolism. Current literature suggests that optimal outcomes are achieved when treatment is initiated within 6 weeks of onset. The treatment paradigm calls for thrombolysis and, frequently, a first rib resection.

Hand knitting induced thrombosis of the subclavian vein in a young woman: an unusual cause of Paget-Schoetter Syndrome

Effort thrombosis refers to axillary-subclavian vein thrombosis associated with strenuous and repetitive activity of the upper extremities. Effort thrombosis usually follows sporting activities, such as wrestling, playing ball, gymnastics and swimming, which involve vigorous andnsustained upper extremity movements. Heretofore, We report a case of Paget-Schroetter syndrome characterized by hand knitting triggered thrombosis of the subclavian vein.

Over Rehearsed

21-year-old black man presented with acute onset of rightarm and shoulder swelling with associated pain one dayafter performing 100 push-ups. He had been previously healthyand active with no significant past medical history. In particular,he had no antecedent history of shoulder trauma or deep venousthrombosis. He was right-handed and played the cello up to 6hours a day. Physical examination on admission was notable foredema involving the right upper arm, shoulder, and infraclavic-ular region. Abduction of the right arm was restricted because ofpain. Jugular venous pressure was not elevated. No dilatedsuperficial or collateral veins were seen on the anterior chestwall. No pulse or neurological deficits were noted in the rightarm at baseline or with attempts at Adson maneuver (neckextension, head away from affected side, and a deep breath).Duplex ultrasound of the right upper extremity revealed acutenonocclusive thrombus in a dilated axillary vein (Figure 1). Thevein walls were partially compressed with external transducerpressure, and spontaneous Doppler flow was minimal withdelayed augmentation on forearm compression. No cervical ribwas seen on chest x-ray, and computerized tomography angiog-raphy of the chest showed no pulmonary emboli. Prothromboticscreen was negative for activated protein-C resistance, pro-thrombingenemutationG20210A,proteinSandCdeficiencies,antithrombin III deficiency, lupus anticoagulant, anticardiolipinantibodies, and hyperhomocysteinemia.The patient was anticoagulated with intravenous unfrac-tionated heparin on admission. His symptoms and edemagradually lessened over the ensuing 4 days. Contrast venog-raphy was performed with the intent to perform catheter-directed thrombolysis, mechanical thrombectomy, or both.Venography revealed patent right axillary and subclavianveins with no evidence of thrombus (Figure 2). Maturecollateral venous communications, however, were foundbetween the axillary and subclavian veins. An Adson maneu-ver performed during venography demonstrated dynamicobstruction of the axillary vein lateral to the thoracic inletwhile flow was still visualized through the venous collateralnetwork (Figure 3). The patient was discharged on oralanticoagulation therapy. Orthopedic opinion is pending forpossible musculoskeletal pathogenesis.Paget-Schroetter syndrome (effort-induced axillary-subclavian vein thrombosis) typically presents after vigorousactivity involving arm abduction, cervical extension, andshoulder depression, especially in the presence of a mechan-ical abnormality at the thoracic inlet where the vein iscompressed between a hypertrophied anterior scalene muscleor subclavius tendon and the first rib. It is postulated thatmicrotrauma to the venous vessel wall activates the coagula-

Power-Pulse Spray Thrombectomy for Treatment of Paget-Schroetter Syndrome

This initial single-center study describes three cases of axillary-subclavian vein thrombosis (Paget-Schroetter syndrome) treated with a rapid, novel thrombectomy technique, termed "power-pulse spray thrombectomy," in which a thrombolytic agent is directly infused into the clot via a catheter, followed by intravascular mechanical clot fracture and removal. All patients in this series were treated in a single session. Complete clot removal was successfully achieved without the development of any complications. This is the first description of the application of this technique in the treatment of Paget-Schroetter syndrome to our knowledge.

Effort Thrombosis of the Upper Extremities Related to an Arm Stretching Exercise

"Effort" axillary-subclavian vein thrombosis (Paget-Schroetter syndrome) is an uncommon deep venous thrombosis due to repetitive activity of the upper limbs. Most cases of this condition are related to strenuous or prolonged sport or occupational activities, while others are associated with endogenous or exogenous risk factors. We report the case of a 43-year-old, previously healthy, male who developed right axillary-subclavian venous thrombosis, which was possibly associated with an exercise involving arm extension and shaking in a posture of shoulder abduction and outstretched for 10 minutes on 2 consecutive days. The condition improved but returned with increased severity when he resumed the exercise after a 2-day break, when he presented with a swollen and bluish arm at the emergency department. Sonographic examination showed moderate thrombotic stenosis of the right axillary vein. Effort thrombosis was diagnosed after ruling out associated coagulopathy or concomitant malignancy. External compression of the accessory ribs or lymph nodes were not detected. He was treated with low molecular weight heparin, followed by oral anticoagulant therapy for 6 months. Only partial resolution of thrombosis was achieved after 6 months of anticoagulant therapy, but pulmonary embolism did not occur during 18 months of follow-up. This case illustrates that, although unusual, Paget-Schroetter syndrome can occur in a healthy patient as a result of mild to moderate exercise.

Transition to an Oral Anticoagulant in Patients With Heparin-Induced Thrombocytopenia

Recommendations for transitioning from therapy with heparin or a low-molecular-weight heparin preparation to therapy with an oral anticoagulant in patients with acute venous or arterial thromboembolism have undergone several changes during the last two decades. Physicians are now comfortable with beginning treatment with an oral anticoagulant once the diagnosis is confirmed, and loading doses are no longer considered to be necessary. Exceptions to early transition may be necessary in patients with an extensive iliofemoral or axillary-subclavian vein thrombosis or pulmonary embolism where thrombolytic agents may be indicated, or in individuals who require surgery or other invasive procedures, or if there are concerns about bleeding. The avoidance of early transition to oral anticoagulants in patients with acute heparin-induced thrombocytopenia also has been advised because of the potential for further thrombotic complications, including venous limb gangrene and warfarin-induced skin necrosis.

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

Prostatic adenocarcinoma masquerading as lymphoma and presentation with axillary-subclavian vein thrombosis

Axillary and/or subclavian vein thrombosis is a relatively rare disease, constituting about 2% of all cases of deep venous thrombosis (DVT). We report on a patient who presented with axillary-subclavian vein thrombosis and had metastatic prostatic adenocarcinoma.

Treatment of subclavian–axillary vein thrombosis: long-term outcome of anticoagulation versus systemic thrombolysis

Objective: To investigate long-term clinical and morphological outcome of patients with subclavian–axillary vein thrombosis treated with systemic thrombolysis compared to anticoagulation in a retrospective, nonrandomised study. Methods: We studied 95 consecutive inpatients with subclavian–axillary vein thrombosis treated either with systemic urokinase thrombolysis and subsequent oral anticoagulation ( n=33) or with anticoagulation only ( n=62). Anticoagulation was performed with heparin and phenprocoumon. Patients were followed for median 40 months (IQR 14 to 94) for symptomatic upper extremity post-thrombotic syndrome and for venous recanalisation by duplex ultrasound. Results: Primary technical success rate of the systemic thrombolysis was 88% ( n=29) with seven peri-intervention bleeding complications (21%). No complication was observed in patients with anticoagulation only ( p<0.0001). At the time of follow-up, duplex sonography showed a thrombotic subclavian vein in 40 of 83 patients (48%), but only 9 of 95 patients (10%) had a symptomatic upper extremity post-thrombotic syndrome. Patients with systemic thrombolysis exhibited a 60% adjusted reduced risk for a thrombotic subclavian vein at the time of follow-up compared to patients with anticoagulation only (95% CI: 0.2 to 0.9, p=0.03). However, the frequency of symptomatic post-thrombotic syndrome after thrombolysis and anticoagulation was similar (adjusted p=0.6). Conclusion: Systemic thrombolysis of subclavian–axillary vein thrombosis has an acceptable primary technical success rate and improves venous recanalisation rates compared to anticoagulation. However, the high rate of complications during thrombolysis and the lack of clinical benefit suggest that conservative treatment may be favoured.

Outcome after thrombolysis and selective thoracic outlet decompression for primary axillary vein thrombosis

Purpose: Treatment for primary subclavian-axillary vein thrombosis (SAVT) at our institution consists of thrombolysis and anticoagulation for 3 months. Thoracic outlet decompression has been performed for a small number of patients. We wanted to review the functional outcomes of patients treated in such a manner. Material And Methods: The records of all patients treated for a first episode of SAVT at our hospital over the past 10 years were reviewed. Demographics, comorbidities, method of diagnosis, and treatment for SAVT were recorded. Long-term follow-up was obtained by chart review and asking patients to complete the DASH (disabilities of the arm, shoulder and hand) questionnaire that was developed by the American Academy of Orthopedic Surgeons. Results: Twenty-eight patients, 20 men and eight women, with a mean age of 36 were treated during the study period. The median time between onset of symptoms and treatment was 5.5 (range, 1-100) days. All patients had confirmation of the diagnosis by venography. Twenty-five patients received thrombolytic treatment with catheter-directed infusions of urokinase; in the other three patients the vein was chronically occluded. Twelve patients had some degree of residual stenosis and were treated with percutaneous transluminal angioplasty after thrombolysis. During the study period two patients underwent decompressive surgery. Twenty-one patients responded to the DASH questionnaire a mean of 2.9 years (range, 2 months to 8 years) after the episode of SAVT. Six (28%) of 21 patients were completely symptom free, 13 patients (62%) had DASH scores consistent with mild symptoms, and two patients had more severe symptoms. Twenty percent (4 of 21) of patients report some difficulty with work. Conclusions: Thrombolysis, followed by selective thoracic outlet decompression on the basis of the severity of patients' symptoms can be used as a therapeutic approach to SAVT without undue morbidity. The DASH questionnaire is a useful tool to evaluate results after therapy for SAVT. (J Vasc Surg 2001;33:783-8.)

Catheter-Directed Thrombolysis for Treatment of Axillary-Subclavian Venous Thrombosis

-Primary axillary-subclavian vein thrombosis with associated symptoms of painful swelling and cyanosis of the upper extremity is best treated with catheter-directed thrombolysis. Following lysis the subclavian vein is evaluated for extrinsic compression, which is frequently observed as the vein crosses the first rib. First rib resection followed by balloon dilation of the stricture and stenting if necessary has proven to be a successful and durable approach. Catheter-directed thrombolysis is also the most effective technique to treat secondary axillary-subclavian venous thrombosis, although in some patients removal of the indwelling catheter and anticoagulation is also a satisfactory therapy.

Catheter-Directed Thrombolysis for Treatment of Axillary-Subclavian Venous Thrombosis

Primary axillary-subclavian vein thrombosis with associated symptoms of painful swelling and cyanosis of the upper extremity is best treated with catheter-directed thrombolysis. Following lysis the subclavian vein is evaluated for extrinsic compression, which is frequently observed as the vein crosses the first rib. First rib resection followed by balloon dilation of the stricture and stenting if necessary has proven to be a successful and durable approach. Catheter-directed thrombolysis is also the most effective technique to treat secondary axillary-subclavian venous thrombosis, although in some patients removal of the indwelling catheter and anticoagulation is also a satisfactory therapy.

Surgical intervention is not required for all patients with subclavian vein thrombosis

Purpose: The role of thoracic outlet decompression in the treatment of primary axillary-subclavian vein thrombosis remains controversial. The timing and indications for surgery are not well defined, and thoracic outlet procedures may be associated with infrequent, but significant, morbidity. We examined the outcomes of patients treated with or without surgery after the results of initial thrombolytic therapy and a short period of outpatient anticoagulation. Methods: Patients suspected of having a primary deep venous thrombosis underwent an urgent color-flow venous duplex ultrasound scan, followed by a venogram and catheter-directed thrombolysis. They were then converted from heparin to outpatient warfarin. Patients who remained asymptomatic received anticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptoms of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent thoracic outlet decompression and postoperative anticoagulation for 1 month. Results: Twenty-two patients were treated between June 1996 and June 1999. Of the 18 patients who received catheter-directed thrombolysis, complete patency was achieved in eight patients (44%), and partial patency was achieved in the remaining 10 patients (56%). Nine of 22 patients (41%) did not require surgery, and the remaining 13 patients underwent thoracic outlet decompression through a supraclavicular approach with scalenectomy, first-rib resection, and venolysis. Recurrent thrombosis developed in only one patient during the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surgery sustained durable relief of their symptoms and a return to their baseline level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging. Conclusion: Not all patients with primary axillary-subclavian vein thrombosis require surgical intervention. A period of observation while patients are receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persistent symptoms and venous obstruction should be offered thoracic outlet decompression. Chronic anticoagulation is not required in these patients. (J Vasc Surg 2000;32:57-67.)

Treatment Alternatives for Axillary—Subclavian Vein Thrombosis: Long-Term Follow-up

Spontaneous axillary—subclavian vein thrombosis in young patients produces long-term disability. Patients with secondary axillary—subclavian vein thrombosis usually require prolonged venous catheterization for chemotherapy or pacemaking. This study aimed to compare the early and late results of lytic versus anticoagulant therapy in the treatment of axillary—subclavian vein thrombosis, both spontaneous and secondary to central venous cannulation. Nine patients underwent conventional treatment (heparin and warfarin) (group 1), and 10 had initial lytic therapy followed by heparin and warfarin (group 2). Three patients had cervical or first rib resection. Thirteen patients had spontaneous thrombosis and six were secondary to central venous catheterization. The mean follow-up was 36 months. Two of nine patients (22%) in group 1 and eight of 10 patients (80%) in group 2 had total venous recanalization and symptom resolution ( P = 0.018). In the spontaneous axillary—subclavian vein thrombosis subset, one of six patients (17%) in group 1 and five of seven patients (71%) in group 2 had total venous recanalization and symptom resolution ( P = 0.078). The average difference in cost per patient between groups 1 and 2 was $19039. In conclusion, lytic therapy appears superior to anticoagulation in the treatment of axillary—subclavian vein thrombosis. However, such treatment is more expensive and its benefits should be carefully weighed against the cost in each case.