Surgical and endovascular treatment of Paget-Schroetter
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Transcript of Surgical and endovascular treatment of Paget-Schroetter
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Image from http://www.nlm.nih.gov/medlineplus/ency/imagepages/8963.htm
INTRODUCTION
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Image from http://www.nlm.nih.gov/medlineplus/ency/imagepages/8963.htm
Anterior scalene muscle
Subclavius muscle
PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY
Anterior scalene muscle
Subclavius muscle
Pinch of the vein in arm abduction
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2 / 100.000 per year
1-4% of all DVT
INCIDENCE
Lindblad B et al. DVT of the axillary-subclavian veins: epidemiologic data, treatment and late sequelae. Eur J Vasc Surg 1988; 2:161-5
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Mean age early 30s
Male to Female ratio 2:1
Right Arm (dominant) 80%
Vigorous exercise 60-80%
EPIDEMIOLOGY
Illig KA and Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010;51:1538-47
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Blue, swollen, painful upper extremity
Edema + dilated superficial veins in arm, neck, chest
Pulmonary embolism 6-15%
NATURAL HISTORY: CLINICAL PRESENTATION
Adams JT and DeWeese JA. Effort thrombosis of the axillary and subclavian veins. J Trauma 1971;11:923-30
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Incidence 15-46%
PTS more severe in dominant arm
Good /excellent quality of life 29%
NATURAL HISTORY: POST-THROMBOTIC SYNDROME
Elman EE et al. The posthrombotic syndrome after upper extremity DVT: a systematic review. Thrombosis Research2006;117:609-614
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Persistent pain / heaviness /cramps
Persistent swelling and edema
Venous dilatation
Functional disability of the arm
Impaired quality of life
NATURAL HISTORY: POST-THROMBOTIC SYNDROME
Elman EE et al. The posthrombotic syndrome after upper extremity DVT: a systematic review. Thrombosis Research2006;117:609-614
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Symptoms of chronic venous obstruction 78%
Moderate-severe 30%
NATURAL HISTORY: POST-THROMBOTIC SYNDROME
Persson LM et al. Hemodynamic and morphologic evaluation of sequelae of primary upper extremity DVT. J Vasc Surg2006;43:1230-5
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Anticoagulation alone
Thrombolytic therapy
Decompression of thoracic outlet
TREATMENT: CONTROVERSIES
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2000-2011 22 patients
14 women / 9 men
Medium age 32 years
Onset of symptoms 3,2 days (SD 7,2)
Sports/Risk profession 72,7%
TREATMENT
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Thrombolityc therapy with urokinase 100.000 U / h
Reimaging 12-hour interval
Mean lysis time 51,2 hours (24-96 h)
Succesful lysis in 100%
TREATMENT
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Endovascular intervention
Thrombolysis alone 75%
Thrombolysis + venoplasty 21%
Thrombolysis + stenting 4%
Transaxillary first rib resection 100%
TREATMENT
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Pneumothorax 4,3%
Horner 4,3%
COMPLICATIONS
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Clinic / Ecodoppler / QuickDASH survey
Mean 54 months
Re-thrombosis 0%
Restenosis 8,7%
Permeability (1, 5 years) 100%
Stent fracture 4,3%
FOLLOW UP
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FOLLOW UP
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QuickDASH (0-100)
Mean 12,5 points (SD 23,1)
Preop 14,9 (SD 18,3) Postop 14,8 (SD 15,5)*
FOLLOW UP: QUALITY OF LIFE
http://www.orthopaedicscore.com/scorepages/disabilities_of_arm_shoulder_hand_score_quickdash.html
* Cordobes J, Lozano P Functional recovery after surgery for TOS. Eur J Vasc Endovasc Surg 2008;35:79-83
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CONCLUSIONS
Low complication rate
Satisfactory long-term outcomes
Good quality of life