A comprehensive review of Paget-Schroetter syndrome

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Presentation transcript:

A comprehensive review of Paget-Schroetter syndrome Karl A. Illig, MD, Adam J. Doyle, MD Journal of Vascular Surgery Volume 51, Issue 6, Pages 1538-1547 (June 2010) DOI: 10.1016/j.jvs.2009.12.022 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 Basic anatomy of the thoracic outlet. The subclavian/axillary vein is located anteriorally, and passes in front of the anterior scalene muscle (shown detached from its origination on the spine). Note the position of the vein between the first rib and clavicle, the position of the subclavius tendon, and the potential for “nutcracker-like” compression by the two bones, even with only minimal movement. m, Muscle; v, vein. Journal of Vascular Surgery 2010 51, 1538-1547DOI: (10.1016/j.jvs.2009.12.022) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 Basic classification of thoracic outlet syndrome. Intermittent positional venous obstruction is felt to be a precursor of effort thrombosis if not recognized and treated. The exact incidences of these conditions is unknown, but their relative frequencies are shown, most common to least common, reading left to right. TOS, Thoracic outlet syndrome. Journal of Vascular Surgery 2010 51, 1538-1547DOI: (10.1016/j.jvs.2009.12.022) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 Effect of arm position on the axillary/subclavian vein at the costoclavicular junction. A, Arm outstretched but less than 90 degrees. Note the absence of obstruction and the absence of collaterals. B, Arm abducted well over 90 degrees. Note the smooth extrinsic compression at the costoclavicular junction and the visualization of the external jugular vein and surrounding collaterals. Journal of Vascular Surgery 2010 51, 1538-1547DOI: (10.1016/j.jvs.2009.12.022) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 Venogram in a patient after thrombolysis with significant residual obstruction. Note that although the obstruction itself is poorly visualized, extensive venous collaterals are present. These are pathognomonic for a hemodynamically significant obstruction to outflow. Journal of Vascular Surgery 2010 51, 1538-1547DOI: (10.1016/j.jvs.2009.12.022) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 5 Algorithm for treatment of patients with partial or complete effort thrombosis. The best initial procedure (more accurately, the chances of success) is defined by the duration of symptoms, whereas the subsequent method of thoracic outlet decompression is defined by the status of the residual vein and residual symptoms. Timing of decompression is not defined in our protocol, although we believe decompression should immediately follow thrombolysis. Journal of Vascular Surgery 2010 51, 1538-1547DOI: (10.1016/j.jvs.2009.12.022) Copyright © 2010 Society for Vascular Surgery Terms and Conditions