Clinical Research| Volume 29, ISSUE 6, P1073-1077, August 2015

Acute Paget–Schroetter Syndrome: Does the First Rib Routinely Need to Be Removed after Thrombolysis?


      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.


      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.


      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.


      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Illig K.A.
        • Doyle A.J.
        A comprehensive review of Paget-Schroetter syndrome.
        J Vasc Surg. 2010; 51: 1538-1547
        • Heron E.
        • Lozinguez O.
        • Emmerich J.
        • et al.
        Long-term sequelae of spontaneous axillary-subclavian venous thrombosis.
        Ann Intern Med. 1999; 131: 510-513
        • Darcy M.
        Surgical techniques: thrombolysis, IVUS, and balloon angioplasty for VTOS.
        in: Illig K.A. Thompson R.W. Freischlag J.A. Thoracic Outlet Syndrome. Springer-Verlag, London2013: 413-421
        • Urschel H.C.
        • Razzuk M.A.
        Paget-Schroetter syndrome: what is the best management?.
        Ann Thorac Surg. 2000; 69: 1663-1668
        • Lee W.A.
        • Hill B.B.
        • Harris J.E.
        • et al.
        Surgical intervention is not required for all patients with subclavian vein thrombosis.
        J Vasc Surg. 2000; 32: 57-67
        • Lee J.T.
        • Karwowski J.K.
        • Harris J.E.
        • et al.
        Long-term thrombotic recurrence after non-operative management of Paget-Schroetter syndrome.
        J Vasc Surg. 2006; 43: 1236-1243
        • Gloviczki P.
        • Kazmier F.J.
        • Hollier L.H.
        Axillary-subclavian venous obstruction: the morbidity of a non-lethal disease.
        J Vasc Surg. 1986; 4: 333-337
        • Swinton N.W.
        • Edgett J.W.
        • Hall R.J.
        Primary subclavian-axillary vein thrombosis.
        Circulation. 1968; 38: 737-745
        • Johansen K.H.
        Controversies in VTOS: is costoclavicular junction decompression always needed in VTOS?.
        in: Illig K.A. Thompson R.W. Freischlag J.A. Thoracic Outlet Syndrome. Springer-Verlag, London2013: 513-515
        • Johansen K.H.
        • Illig K.A.
        Conservative (nonoperative) treatment of VTOS.
        in: Illig K.A. Thompson R.W. Freischlag J.A. Thoracic Outlet Syndrome. Springer-Verlag, London2013: 395-400
        • Gloviczki P.
        • Kazmaier F.S.
        • Hollier L.H.
        Axillary-subclavian venous occlusion: the morbidity of a non-lethal disease.
        J Vasc Surg. 1986; 4: 333-337
        • Stone D.H.
        • Scali S.T.
        • Bierk A.A.
        • et al.
        Aggressive treatment of idiopathic axillosubclavian vein thrombosis provides excellent long-term function.
        J Vasc Surg. 2010; 52: 127-131
        • Schneider D.B.
        • Dimuzio P.B.
        • Martin N.D.
        • et al.
        Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty.
        J Vasc Surg. 2004; 40: 599-603
        • Molina J.E.
        • Hunter D.W.
        • Dietz C.A.
        Protocols for Paget Schroeder syndrome and late treatment of chronic subclavian vein obstruction.
        Ann Thorac Surg. 2009; 87: 416-422
        • Doyle A.
        • Wolford H.
        • Davies M.G.
        • et al.
        Management of effort thrombosis of the subclavian vein: today's treatment.
        Ann Vasc Surg. 2007; 21: 723-729
        • Guzzo J.L.
        • Chang K.
        • Demos J.
        • et al.
        Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis.
        J Vasc Surg. 2010; 52: 658-663
        • Lee M.C.
        • Grassi C.J.
        • Belkin M.
        • et al.
        Early intraoperative intervention after thrombolytic therapy for primary subclavian vein thrombosis: an effective approach.
        J Vasc Surg. 1998; 27: 1101-1108
        • Sabeti S.
        • Schillinger M.
        • Mlekusch W.
        • et al.
        Treatment of subclavian-axillary vein thrombosis: long-term outcome of anticoagulation versus systemic thrombolysis.
        Thromb Res. 2002; 108: 279-285
        • Machleder H.I.
        Evaluation of a new treatment strategy for Paget Schroeder syndrome: spontaneous thrombosis of the axillary-subclavian vein.
        J Vasc Surg. 1993; 17: 305-317
        • Lokanathan R.
        • Salvian A.J.
        • Chen J.C.
        • et al.
        Outcome after thrombolysis in selective thoracic outlet decompression for primary axillary vein thrombosis.
        J Vasc Surg. 2001; 33: 783-788
        • Martinelli I.
        • Battoglioli T.
        • Bucciaralli P.
        • et al.
        Risk factors and recurrence rates of primary deep venous thrombosis of the upper extremities.
        Circulation. 2004; 110: 566-570
        • Lechner D.
        • Wiener C.
        • Weltermann A.
        • et al.
        Comparison between idiopathic deep vein thrombosis of the upper and lower extremity regarding risk factors and recurrence.
        J Thromb Haemost. 2008; 6: 1269-1274
        • Hingorani A.
        • Ascher E.
        • Lorenson E.
        • et al.
        Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population.
        J Vasc Surg. 1997; 26: 853-860
        • Doyle A.J.
        Outcomes after treatment of VTOS.
        in: Illig K.A. Thompson R.W. Freischlag J.A. Thoracic Outlet Syndrome. Springer-Verlag, London2013: 471-491