Long-term Thrombotic Recurrence After Non-operative Management of Paget-Schroetter Syndrome

Jason T. Lee, MD, Stanford University Medical Center, Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA; John K. Karwowski, MD, Stanford, CA; E. John Harris, MD, Stanford, CA; Cornelius Olcott,IV, MD, Stanford, CA;

Purpose: The purpose of this study is to determine clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with non-operative management of patients with primary subclavian vein thrombosis.
Methods: 64 patients treated for Paget-Schroetter syndrome from 1996-2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First rib resection was performed in 29 patients (45%) within the first three months with a success rate of 93%. The remaining 35 patients (55%) were treated non-operatively and constitute the study population.
Results: Of the 35 patients with successful non-operative management, seven (20%) developed recurrent thrombotic events 15.3 months post-thrombolysis (range 6 to 34 months). These seven patients went on to have first rib resection and resolution of symptoms at a mean follow-up time of 54 months (range 12-100). The other 28 patients remain symptom-free at a mean follow-up interval of 46 months (range 6-100). Univariate analysis determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P=0.035). The recurrence group was also significantly younger than the asymptomatic group (23.1 vs. 35.4 years, P=0.02). Gender, being a competitive athlete, length of time on coumadin, history of trauma, response to original lysis, and initial clot burden on venogram were all parameters not associated with long-term recurrence after non-operative management.
Conclusions: Conservative non-operative management of primary subclavian vein thrombosis can be successfully employed with acceptable long-term results. Younger age and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.