Paget-Schroetter Syndrome

Author: Lindsay Gates, MD
Institution: Yale University
Date Reviewed: May 2014
Learning Domain: General Thoracic
Learning Objective: Evaluation of and Surgical Management of Paget-Schroetter Syndrome
PowerPoint File: Paget-Schroetter Syndrome

Discussion Points

• What causes Paget-Schroetter’s Syndrome (PSS) or Venous Thoracic Outle Syndrome, (vTOS)?
• What clinical findings are suggestive of TOS
• How is TOS diagnosed?
• What are the treatment strategies?
• What are the operative options?

Cause of PSS

• Thrombosis of severe narrowing of the subclavian-axillary vein due to chronic extrinsic mechanical compression.
• “Effort Thrombosis”
  • Associated with young, healthy individuals
  • Repetitive arm and shoulder motion.  

Anatomic Considerations

• Key Anatomic Structures Contributing to venous compression 
  • First Rib
  • Clavicle
  • Subclavius Muscle
  • Fibrous Costocoracoid Ligament
  • Anterior Scalene Muscle and tubercle

Schanzer A., and Messina L.  “Thoracic Outlet Syndrome-Venous”. Rutherford’s Vascular Surgery.  7th ed.  

Diagnosis

• Duplex Ultrasound
• Magnetic Resonance Venography
• Computed Tomagraphic Venoography
• Conventional Venography-  “Gold Standard”

Treatment

• Anticoagulation Alone:
  • High rates of residual functional impairment  (40-74%)
• Thrombolytic Therapy
  • Within 14 days of onset of symptoms yields high rates of successful restoration of luminal patency
• Surgical Decompression
  • After successful thrombolysis
  • Patients with signs of extrinsic compression

Learning Points

• Paget Schroetter’s Syndrome is rare disorder usually found in young, healthy patients
• Due to chronic extrinsic mechanical compression of the subclavian or axillary vein
• Patient’s often need thrombolysis followed by surgical decompression 
  • Early intervention key
• Operative risks include: nerve injury (phrenic and brachial plexus), pneumothorax, and recurrence
• Without intervention, high risk of long-term functional impairment