UCLA Sequence of Rx for Spectrum of Clinical Symptoms Subclavian - - PowerPoint PPT Presentation

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UCLA Sequence of Rx for Spectrum of Clinical Symptoms Subclavian - - PowerPoint PPT Presentation

Jul 15, 2023 284 likes •362 views

4/18/2013 Should Subclavian Vein Thrombosis Always Be Scope of Problem: Subclavian Vein Occlusion Treated with Rib Resection? How We Decide Paget-Schroetter Syndrome or Effort Thrombosis 2/100,000/year; 3000-6000 cases in US/year

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4/18/2013 1 Should Subclavian Vein Thrombosis Always Be Treated with Rib Resection? How We Decide

Peter F. Lawrence MD Gonda Vascular Center Division of Vascular Surgery David Geffen School of Medicine, UCLA

Scope of Problem: Subclavian Vein Occlusion

Paget-Schroetter Syndrome or “Effort Thrombosis”

  • 2/100,000/year; 3000-6000 cases in US/year
  • Mean age early 30’s; M:F =2:1
  • 1-4% of all cases of venous thrombosis
  • More common on right; 60-80% report vigorous exercise
  • Common in athletes, particularly baseball

Melby SJ, Vedantham S, et al. Comprehensive surgical management

  • f the competitive athlete with effort thrombosis of the subclavian vein.

J Vasc Surg 2008

Normal Anatomy Compression on Arm Abduction and Rotation

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Spectrum of Clinical Symptoms with Paget Schroetter’s

  • Asymptomatic
  • Intermittent arm pain and

swelling with activity

  • Constant arm

swelling/pain

  • 85% of patients admit to

regular exercise with arm elevation/abduction

UCLA Sequence of Rx for Subclavian Vein Thrombosis

  • Brachial approach to subclavian vein.; thrombolysis-immediate
  • Anticoagulation- days to months
  • Repeat duplex ultrasound for patency- days to months
  • Transaxillary removal of 1st rib +division of subclavius tendon+

removal of cervical rib in rare cases- days to months

  • Repeat venogram with stress if needed- correct the residual stenosis

–days to months – Balloon angioplasty – IJ turndown/endovenorrhaphy

– Never stent PS due to high risk of restenosis

Angle N, Gelabert HA, et al. Early surgical decompression of the thoracic outlet for Paget- Schroetter syndrome. Ann Vasc Surg 2001

Venous Occlusive Disease and Compression Syndromes : Paget-Schroetter Syndrome

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Usually cross with 0.35 hydrophilic wire and Glidecath, but

  • ccasionally need a low profile Quick-Cross

Venous Occlusive Disease and Compression Syndromes : Paget-Schroetter Syndrome Venous Occlusive Disease and Compression Syndromes : Paget-Schroetter Syndrome

Gelabert HA, Jimenez JC, et al. Comparison of retavase and urokinase for management of spontaneous subclavian vein thrombosis. Ann Vasc Surg 2007

UCLA Surgical Approach

Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet compression syndrome. Ann Surg1966

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Venous Occlusive Disease and Compression Syndromes : Superior Vena Cava Syndrome

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Results

  • 39 patients presented with symptomatic subclavian

vein thrombosis on average 27 weeks post event

  • All underwent first rib resection and scalenectomy

– 25/39 (64%) had residual post rib resection subclavian vein stenosis and underwent angioplasty – 13/39 had no residual stenosis and were not dilated (should have had IVUS and been W/U for hypercoagulability) – 1 rethrombosed and underwent lysis and dilatation

  • 2/3 required PTA and then anticoagulation for 3

months

De Leon et al Surgery 2009

Results (Long-term)

  • 96% patency of the subclavian vein
  • No vascular injuries
  • No brachial plexus or long thoracic nerve

injuries

  • 15% pneumothorax- no Rx required

De Leon et al Surgery 2009

“McCleery Syndrome”

  • 11/67(16%) presented at 57 weeks with swelling

but no thrombosis

  • All demonstrated vein occlusion with abduction
  • All underwent 1st rib resection and

scalenectomy

  • All became asymptomatic

De Leon et al Surgery 2009

Management of PS with No Compression Visualized by Venogram

  • Imaging

– Stress venographic views for compression – ? IVUS

  • Workup for hypercoagulable state (25%

will have it)

  • No removal of the 1st rib if no compression
  • ? Length of anticoagulation

Cassada DC, Lipscomb AL, et al. The importance of thrombophilia in The treatment of Paget-Schroetter syndrome. Ann Vasc Surg 2006

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Remaining Questions

  • Management of contralateral 1st rib if

compression is demonstrated

  • Management of asymptomatic patient
  • Management of chronic occlusion with

symptoms

– Venous bypass – Endovenectomy – Stent –never! for P-S TOS but consider for SVC syndrome

How We Decide When Subclavian Vein Thrombosis Should Be Treated with Rib Resection?

  • Symptomatic
  • Thrombolysis reopens the subclavian vein
  • Vein remains patent
  • There is compression or fixed stenosis due

to the rib