Paget-Schroetter syndrome: A contemporary review of the controversies in management

Abstract

Aim To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome. Materials and methods We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome. Results There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed. Conclusions Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.

Same Admission Hybrid Treatment of Primary Upper Extremity Deep Venous Thrombosis with Thrombolysis, Transaxillary Thoracic Outlet Decompression, and Immediate Endovascular Evaluation

“…11,12,21,25,26 Besides, the optimal timing for these procedures is debatable. 27 Venous reconstruction procedures, in particular vein patch placements, are described in several cohorts with excellent patency rates. 21,28 To adequately place a patch on the ASV, at least an infraclavicular approach should be performed.…”

“…There is a lot of controversy on this issue. In some articles there is concern about long-term patency 12,33e35 or limited options for later venous reconstruction, 27,33,34 whereas another article claims excellent results. 36 We reserve stent placement for persistent residual lesions in patients with severe sequelae despite several PTAs.…”

Paget-Schroetter Syndrome in a Young Female

“…14 Guidelines currently practicing are based on the small case series, single institutional case studies, and vascular surgery expert opinions with promising results. 15 No randomized controlled trials are available to assess surgical and catheter-directed thrombolysis' efficacy and safety, and further prospective large multicenter studies are needed. There is no statistically significant difference in the symptom resolution in the groups with first rib resection in less or more than 6 weeks.…”

The treatment of upper extremities deep vein thrombosis related to thoracic outlet syndrome with direct oral anticoagulants

“…Few quality data for the anticoagulant treatment of primary thrombosis due to VTOS are reported: case series of VTOS UEDVT treated with low molecular weight heparin or vitamin K antagonists showed a thrombosis recurrence in 72% of patients within the 6 weeks from the start of oral anticoagulation alone, higher than that reported for other causes of UEDVT. 5 Clinical experiences appear to suggest that without recanalization of the axillo-subclavian vein and removal of the precipitant anatomical defect, patients are at high risk of re-thrombosis and PTS. 6 Although small, our study suggests that DOACs may be effective and safe in patients with UEDVT related to VTOS, when the endovascular/surgery approach is not possible.…”

“…The DOACs used were apixaban and rivaroxaban. On the basis of patients’ preference, 5 patients were treated with apixaban 5 mg twice daily and 5 with rivaroxaban 20 mg daily. Oral anticoagulation full dose was continued for 12 months (acute phase) and patients were evaluated every 6 months with Doppler ultrasound.…”