Paget–Schroetter syndrome is a clinical diagnosis confirmed by duplex ultrasound and venogram. The ipsilateral arm frequently is swollen with distended veins up to the shoulder. Range of motion of the arm is impaired as a result of pain. If not treated immediately, the patient may be left with a chronic debilitating condition that limits use of the arm. Lysis of the clot alone or anticoagulation alone is inadequate therapy. The surgeon must be prepared to divide the compressive muscles and to perform a patch angioplasty of the vein to restore its normal caliber. We describe the operative approaches to affect this type of repair.
Paget–Schroetter syndrome is rare, and the average surgeon may see only a few cases across a career. J. Ernesto Molina is a cardiothoracic surgeon at the University of Minnesota who developed an interest in treatment protocols for this disease. He has educated a generation of surgeons from the University of Minnesota program, and this chapter is indebted to his work.3–6
The diagnosis of Paget–Schroetter syndrome is based on history, physical examination, and Doppler assessment of the ipsilateral axillary and subclavian veins. The history is one of recent efforts of the ipsilateral arm and sudden pain. The physical examination generally reveals a swollen and functionally impaired forearm and hand. Although distention of arm veins is seen commonly, development of venous collaterals around the shoulder is a late finding and suggestive of a chronic condition. Doppler ultrasound shows venous occlusion with thrombosis of various extent.
At the University of Minnesota since the early 1990s, this diagnosis has been followed by the placement of a venous catheter, which is advanced into the clot. The catheter provides access for a venogram to assess the length of the clot, as well as for local delivery of fibrinolytics. Although urokinase was initially used as our preferred thrombolytic agent in the 1980s, this now has been supplanted by recombinant tissue plasminogen activator (Activase, Alteplase, TNK-TPA). The catheter-directed infusion of thrombolytics at recommended doses is a very safe procedure with no systemic bleeding complications. The clot always dissolves within 24 hours of infusion, and as soon as that stage is reached, thrombolysis is discontinued and the patient is prepared for surgery, which should follow within a few hours.