Background
Most clinicians feel that treatment for patients with acute primary axillosubclavian
vein thrombosis (“effort thrombosis”) is catheter-directed thrombolysis followed by
thoracic outlet decompression. Several investigators feel that first rib resection
(FRR) is not indicated in every case. No randomized data exist to answer this question.
Methods
A MEDLINE search was done using the terms “Paget-Schroetter syndrome,” “upper extremity
DVT,” “first rib resection,” “effort thrombosis,” and “primary upper extremity thrombosis,”
with thrombolysis used as an “AND” term. We also specifically explored references
cited to support either side of this argument in the past. Analysis was limited to
patients aged 18 years or older with symptoms of 14-day duration or less undergoing
thrombolysis for primary axillosubclavian vein thrombosis. Those studies that did
not report follow-up, duplicate series from the same institution, and those in which
patients were stented were excluded. Results were analyzed on an intent-to-treat basis,
with groups assigned according to each authors' prospectively described algorithm.
Results
Twelve series were included. Patients were divided into 3 groups according to treatment
after thrombolysis: FRR (448 patients), FRR plus endovenous balloon venoplasty (FRR + PLASTY;
68 patients), and those with no further intervention after thrombolysis (rib not removed;
168 patients). Symptom relief at last follow-up was significantly more likely in the
FRR (95%) and FRR + PLASTY (93%) groups than in the rib not removed (54%) group (both
<0.0001) as was patency (98%, 86%, and 48%, respectively; both <0.0001 vs. rib not
removed). More than 40% of patients in the rib not removed group eventually required
rib resection for recurrent symptoms. No differences in symptom-free rates were seen
when comparing FRR with FRR + PLASTY.
Conclusions
In patients with acute effort thrombosis who undergo thrombolysis, permanent symptom
relief and long-term patency are more likely to be achieved in patients who undergo
FRR with or without endovenous balloon venoplasty than those whose rib is left intact.
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Article info
Publication history
Published online: May 19, 2015
Accepted:
February 18,
2015
Received:
December 12,
2014
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
