Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome)

• Published in: Journal of vascular surgery 2008-04, Vol.47 (4), p.809-820.e3
• Main Authors: Melby, Spencer J., MD, Vedantham, Suresh, MD, Narra, Vamsidhar R., MD, Paletta, George A., MD, Khoo-Summers, Lynnette, MSPT, Driskill, Matt, MSPT, Thompson, Robert W., MD
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Anticoagulants - therapeutic use; Female; Humans; Length of Stay; Male; Patient Care Team; Phlebography; Sports; Subclavian Vein - surgery; Surgery; Thoracic Outlet Syndrome - diagnosis; Thoracic Outlet Syndrome - rehabilitation; Thoracic Outlet Syndrome - surgery; Thoracic Outlet Syndrome - therapy; Thrombolytic Therapy; Treatment Outcome; Vascular Surgical Procedures - methods; Venous Thrombosis - diagnosis; Venous Thrombosis - rehabilitation; Venous Thrombosis - surgery; Venous Thrombosis - therapy
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2007.10.057

Objectives The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes. Methods A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care. Results Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 ± 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 ± 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation ( r = 0.820, P < .001) and was longer in patients with persistent symptoms ( P < .05) or rethrombosis before referral ( P < .01). Conclusions Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with exter