Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) Spencer J. Melby,

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Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) Spencer J. Melby, MD, Suresh Vedantham, MD, Vamsidhar R. Narra, MD, George A. Paletta, MD, Lynnette Khoo-Summers, MSPT, Matt Driskill, MSPT, Robert W. Thompson, MD Journal of Vascular Surgery Volume 47, Issue 4, Pages 809-820.e3 (April 2008) DOI: 10.1016/j.jvs.2007.10.057 Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 1 Distribution of patients, diagnosis, and referral. A, Distribution of 276 consecutive patients undergoing operative treatment for thoracic outlet syndrome (TOS) at Washington University from January 1997 to January 2007. The subset of competitive athletes with venous TOS is indicated. B, Use and results of upper extremity duplex ultrasound examinations in the initial diagnosis of suspected effort thrombosis in 32 competitive athletes. C, Location of initial venographic diagnosis, treatment, and referral for surgical management. Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 2 Radiographic and operative findings in venous thoracic outlet syndrome. A-C, Gadolinium-enhanced magnetic resonance (MR) venogram in a 26-year-old right-handed baseball player demonstrates right subclavian vein occlusion (arrows) with the arms in (A) neutral and (B) elevated positions that correspond to the lesion subsequently observed by (C) direct contrast venography. D-F, Contrast venograms in a 26-year-old right-handed baseball pitcher with (D) a long segment subclavian vein occlusion on the initial study (arrow), (E) improved flow and appearance with focal subclavian vein stenosis 22 hours after thrombolysis (arrow), and (F) focal subclavian vein occlusion with arm elevation (arrow). G, In this typical operative specimen of the left first rib excised during paraclavicular thoracic outlet decompression, the scalene tubercle is indicated (arrow). H, This operative photograph of the left subclavian vein after circumferential external venolysis shows thick residual scar tissue encasing the proximal subclavian vein and restricting its diameter even after complete mobilization (arrow). A saphenous vein panel graft bypass was performed from the end of the normal subclavian vein to the side of the jugular-subclavian vein junction (asterisks), with excision of the intervening native subclavian vein. I, Operative specimen of the subclavian vein containing an indwelling stent (arrow, inset), which was excised during paraclavicular decompression and subclavian vein bypass graft reconstruction. J-L, Drawings show the techniques used for (J) subclavian vein patch angioplasty, (K) excision of the obstructed proximal segment of the subclavian vein, and (L) surgical reconstruction with interposition bypass using a saphenous vein panel graft. IJV, Internal jugular vein; SCV, subclavian vein; BCV, brachiocephalic (innominate) vein. M, Initial contrast venogram in a 20-year-old baseball pitcher presenting with right arm swelling and extensive axillary-subclavian vein thrombosis. N, Venogram immediately after thrombolysis and balloon angioplasty. O, Repeat venogram after 2 months of anticoagulation, during which the patient had persistent symptoms. The appearance of chronic recurrent axillary-subclavian vein occlusion was considered inoperable before referral. P, Follow-up postoperative venogram after thoracic outlet decompression and subclavian vein reconstruction using a saphenous vein panel graft illustrates a widely patent venous system and absence of collateral flow. The patient experienced prompt relief of arm swelling and returned to competitive baseball 4 months later. Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 3 Time-course of clinical management and return to athletic activity. A, The bars on the graph illustrate the overall time-course of clinical management for 32 competitive athletes with effort thrombosis. Interval A represents the time from the onset of symptoms to venographic diagnosis; interval B represents the time from venographic diagnosis to operative treatment; interval C represents the period of postoperative hospitalization; and interval D represents the time from operation to a complete return to athletic activity. The numbers in brackets indicate the total duration of management from the initial symptoms to a complete return to athletic activity. B, Scatter plot shows the association between the overall duration of management (the time from initial symptoms to the complete return to competitive athletics) and the time interval from diagnosis to operation. Data were compared using the Pearson correlation test, with a two-tailed value of P < .05 considered significant. Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 4 Graphs show the effects of initial management and previous rethrombosis on clinical outcomes after surgical treatment. Patient outcomes were analyzed according to the initial management: group I, initial management at Washington University/ Barnes-Jewish Hospital (WU/BJH) in St Louis, or elsewhere with direct referral to WU/BJH; group II, initial management elsewhere with persistent symptoms and late referral; and group III, initial management elsewhere with documented subclavian vein rethrombosis and late referral. A, Interval A represents the time from the onset of symptoms to venographic diagnosis. B, Interval B represents the time from venographic diagnosis to operative treatment. C, Interval C represents the period of postoperative hospitalization. D, Interval D represents the time from operation to a complete return to athletic activity. E, Interval A-D indicates the overall duration of management from the initial symptoms to a complete return to athletic activity. Values represent the mean ± standard error of the mean. Statistical comparisons between groups were made using analysis of variance; Pvalues associated with post-hoc multiple comparisons testing are indicated (NS, not significant). Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Supplemental A, I Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Supplemental A, II Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Supplemental A, III Journal of Vascular Surgery 2008 47, 809-820.e3DOI: (10.1016/j.jvs.2007.10.057) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions