Subclavian Effort and Upper Limb Thrombosis – a Lesson Learned

Abstract

Subclavian vein effort and upper limb thrombosis, known as the Paget-Schroetter syndrome (PSS), accounts for 30–40 % of spontaneous upper extremity deep vein thromboses (UEDVTs) and 10–20 % of all upper limb deep vein thromboses (DVTs). As complication of PSS include post-thrombotic syndrome and pulmonary embolism, early recognition and prompt initiation of anticoagulant treatment is crucial in the course of its treatment. PSS is associated with single or repeated physical activity of the upper limb, combined with obstruction of venous outflow resulting from anatomical alterations. A correct diagnosis, based on a range of imaging methods, and prompt initiation of local thrombolytic therapy, surgical decompression of the thoracic outlet (when necessary), and immediate initiation of anticoagulant treatment, aim to effectively restore the patient life quality, preventing post-thrombotic syndrome and recurrent thrombosis.

Zusammenfassung

Die Effort-Thrombose der Vena subclavia und die Thrombose der oberen Gliedmaßen werden als Paget-Schroetter-Syndrom (PSS) bezeichnet. Sie machen 30–40% der spontanen tiefen Venenthrombosen der oberen Extremitäten und 10–20% aller tiefen Venenthrombosen der oberen Extremitäten aus. Zu den Komplikationen des PSS werden das postthrombotische Syndrom und die Lungenembolie gezählt. Daher sind das frühzeitige Erkennen und die unverzügliche Einleitung einer gerinnungshemmenden Behandlung für den Verlauf von entscheidender Bedeutung. Das PSS tritt bei einmaliger oder wiederholter körperlicher Betätigung der oberen Gliedmaßen in Verbindung mit einer Obstruktion des venösen Abflusses infolge anatomischer Veränderungen auf. Eine korrekte Diagnose auf der Grundlage verschiedener bildgebender Verfahren und die unverzügliche Einleitung einer lokalen Thrombolysetherapie – einer chirurgischen Dekompression des Thoraxauslasses (falls erforderlich) und die sofortige Einleitung einer gerinnungshemmenden Behandlung – sollen die Lebensqualität des Patienten wirksam wiederherstellen und ein postthrombotisches Syndrom sowie eine erneute Thrombose verhindern.

Schlüsselwörter

Tiefe Venenthrombose der oberen Extremitäten - Thoracic-Outlet-Syndrom - Thrombose der Vena subclavia - Paget-Schroetter-Syndrom - Thrombolyse - Resektion der ersten Rippe

Keywords

upper extremity deep vein thrombosis - thoracic outlet syndrome - subclavian vein thrombosis - Paget-Schroetter syndrome - thrombolysis - first rib resection

Publikationsverlauf

Artikel online veröffentlicht:
29. November 2022

• References

• 1 Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010; 51: 1538-1547 DOI: 10.1016/j.jvs.2009.12.022. (PMID: 20304578)
• 2 Hughes ES. Venous obstruction in the upper extremity; Paget-Schroetter’s syndrome; a review of 320 cases. Surg Gynecol Obstet 1949; 88: 89-127 DOI: 10.1111/pace.14266. (PMID: 33974720)
• 3 Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2002; 28: 89-99 DOI: 10.1055/s-2002-20567. (PMID: 11885029)
• 4 Fisher JB, Granson MA. Congenital venous web causing subclavian vein obstruction: a case report. J Vasc Surg 1989; 10: 460 DOI: 10.1067/mva.1989.14209. (PMID: 2795771)
• 5 Yamashita Y, Morimoto T, Amano H. et al. Deep vein thrombosis in upper extremities: Clinical characteristics, management strategies and long-term outcomes from the COMMAND VTE Registry. Thromb Res 2019; 177: 1-9 DOI: 10.1016/j.thromres.2019.02.029. (PMID: 30825719)
• 6 Pukacki P, Juszkat R, Błaszyk M. et al. Upper extremity deep vein thrombosis: pathogenesis and treatment. Acta Angiol 2019; 25: 115-119
• 7 Alla VM, Natarajan N, Kaushik M. et al. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med 2010; 11: 358-362 (PMID: 21079709)
• 8 Hussain MA, Aljabri B, Al-Omran M. Vascular Thoracic Outlet Syndrome. Semin Thorac Cardiovasc Surg 2016; 28: 151-157 DOI: 10.1053/j.semtcvs.2015.10.008. (PMID: 27568153)
• 9 Machleder H. The anterior scalene muscle in thoracic outlet compression syndrome. Archives of Surgery 1986; 121: 1141 DOI: 10.1001/archsurg.1986.01400100047009. (PMID: 3767646)
• 10 Chang KZ, Likes K, Demos J. et al. Routine venography follow- ing transaxillary first rib resection and scalenectomy (FRRS) for chronic subclavian vein thrombosis ensures excellent outcomes and vein patency. Vasc Endovascular Surg 2012; 46: 15-20 DOI: 10.1177/1538574411423982. (PMID: 22156150)
• 11 Bosch FTM, Nisio MD, Büller HR. et al. Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis. J Clin Med 2020; 9: 2069 DOI: 10.3390/jcm9072069. (PMID: 32630244)
• 12 Di Nisio M, Van Sluis GL, Bossuyt PM. et al. Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis: a systematic review. J Thromb Haemost 2010; 8: 6840 DOI: 10.1111/j.1538-7836.2010.03771.x. (PMID: 20141579)
• 13 Constans J, Salmi L, Sevestre-Pietri MA. et al. A clinical prediction score for upper extremity deep venous thrombosis. Thromb Haemost 2008; 99: 202-207 DOI: 10.1160/TH07-08-0485. (PMID: 18217155)
• 14 Vedantham S. Valvular dysfunction and venous obstruction in the postthrombotic syndrome. Thromb Res 2009; 123: S62-S65 DOI: 10.1016/S0049-3848(09)70146-X. (PMID: 19303507)
• 15 Kearon C, Akl EA, Comerota AJ. et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e419S-494S DOI: 10.1378/chest.11-2301. (PMID: 22315268)
• 16 Wagman LD, Baird MF, Bennett CL. et al. Venous thromboembolic disease. NCCN. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2008; 6: 716-753 DOI: 10.6004/jnccn.2008.0055. (PMID: 18926086)
• 17 Vazquez FJ, Paulin P, Poodts D. et al. Preferred management of primary deep arm vein thrombosis. Eur J Vasc Endovasc Surg 2017; 53: 744-751 DOI: 10.1016/j.ejvs.2016.11.028. (PMID: 28342731)
• 18 Vemuri C, Salehi P, Benarroch-Gampel J. et al. Diagnosis and treatment of effort-induced thrombosis of the axillary subcla- vian vein due to venous thoracic outlet syndrome. J Vasc Surg Venous Lymphat Disord 2016; 4: 485-500 DOI: 10.1016/j.jvsv.2016.01.004. (PMID: 27639006)
• 19 Molina JE, Hunter DW, Dietz CA. Paget-Schroetter syndrome treated with thrombolytics and immediate surgery. J Vasc Surg 2007; 45: 328 DOI: 10.1016/j.jvs.2006.09.052. (PMID: 17264012)
• 20 Schneider DB, Dimuzio PJ, Martin ND. et al. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty. J Vasc Surg 2004; 40: 599 DOI: 10.1016/j.jvs.2004.07.028. (PMID: 15472583)
• 21 Grant JD, Stevens SM, Woller SC. et al. Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost 2012; 108: 1097-1108 DOI: 10.1160/TH12-05-0352. (PMID: 23093319)