Preoperative Thrombolysis Affords Significant Benefit in Patency and Outcome After First Rib Resection in Acute Paget-Schroetter Syndrome

Spontaneous thrombosis of the subclavian vein (Paget-Schroetter syndrome [PSS]) has long been managed with anticoagulation alone. The definitive benefits of thrombolysis in the acute period (first 2 weeks after thrombosis) compared with anticoagulation have not been well reported. Our goal was to compare patients treated with early thrombolysis followed by anticoagulation and first rib resection (FRR) and those treated with anticoagulation and FRR using vein patency according to venography and standardized outcome measures. We reviewed a prospectively collected database from 2000 to 2019. Two groups were compared: those treated with acute (within 2 weeks of onset) thrombolysis at our institution (Lysis group) and those treated with anticoagulation alone (NoLysis group). All patients had undergone FRR. Venography was routinely performed both before and after FRR. Standardized outcome measures included Quick Disability of Arm, Shoulder and Hand (QuickDASH) scores and the somatic pain scale. A total of 100 subjects were identified: 50 in the Lysis group and 50 in the NoLysis group. No difference was present in age (31.4 vs 35.7 years; P = .07), proportion of male patients (44% vs 54%), or laterality (right, 74% vs 72%). On venography before FRR, thrombolysis resulted in patency of 86% of the Lysis group veins. In contrast, 76% of the NoLysis veins were patent. After FRR, postoperative venography with interventions resulted in a significantly greater final vein patency rate for the Lysis group than for the NoLysis group (94% vs 72%; P = .006). Follow-up averaged 227 days for the Lysis group and 276 days for the NoLysis group. The final QuickDASH scores were significantly improved (lower) for the Lysis group vs the NoLysis group (6.6 vs 16.0; P = .049). However, the somatic pain scale score was not significantly different between the two groups (0.2 vs 0.5; P = .37). Subgroup analysis showed that the Lysis group had a significantly greater final vein patency rate among physically active patients (97% vs 70%; P = .039) and a trend toward better QuickDASH scores (7.1 vs 10.7; P = .57; Table). Thrombolysis as initial management of PSS, although not uniformly successful in establishing patency before FRR, resulted in improved final vein patency and improved QuickDASH scores. Thrombolysis should be the management of choice in the setting of acute spontaneous subclavian vein thrombosis (PSS).TableSummary of resultsOutcomeAll (N = 100)Lysis group (n = 50)NoLysis group (n = 50)P valuePre-FRR vein patency81 (81)43 (86)38 (76).31Post-FRR venogram Recanalization plus angioplasty18 (18)17 (34)1 (2).0001 Angioplasty alone53 (53)22 (44)31 (62).11 No intervention12 (12)8 (16)4 (8).36 Failed recanalization17 (17)3 (6)14 (28).006Final vein patency83 (83)47 (94)36 (72).006Final QuickDASH score11.8 ± 166.6 ± 1316.0 ± 17.049Somatic pain scale score0.3 ± 1.30.2 ± 1.30.5 ± 1.2.37FRR, First rib resection; Lysis, treatment with acute (within 2 weeks of onset) thrombolysis; NoLysis, treatment with anticoagulation alone; QuickDASH, Quick Disability of Arm, Shoulder and Hand. Open table in a new tab