Misdiagnosis and Treatment of Paget-Schroeter Syndrome

Commentary

Submitted on Wed, 08/04/2010 - 15:49
Authors

Ross Milner, MD


VASCULAR DISEASE MANAGEMENT 2010;7:E178

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Upper-limb deep venous thrombosis (DVT), Paget-Schroetter syndrome, or effort thrombosis, is a problem that is commonly misdiagnosed and improperly treated. The authors present a straightforward case of upper-limb DVT that appropriately highlights the diagnosis and management of this problem, while raising an important management issue. As mentioned by the authors, effort thrombosis usually occurs in younger patients. It is usually accompanied by a history of frequent, repetitive upper-extremity movements. Ultrasound can usually make the diagnosis. This allows for the decision to treat with a venogram and thrombolysis. Mechanical thrombectomy can also be utilized to achieve a successful result. After successful thrombolysis, a decision can be made for the timing of a first rib resection. Some physicians recommend removing the first rib during the same hospitalization. Others recommend waiting 4–6 weeks before the first rib surgery. I think many people are transitioning to immediate resection, and this is my preference as well. I think the authors have described the identification of this problem well, and I wholeheartedly agree with the thrombolytic therapy. However, I disagree with not removing the first rib. I believe successful thrombolysis will minimize the risk of developing post-phlebitic syndrome. I am concerned that the risk of life-long anticoagulation in a young patient poses a higher risk than the surgery, thus, I would have counseled the patient differently.

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From the Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, Illinois. The author reports no conflict of interest regarding the content herein. Address for correspondence: Ross Milner, MD, Associate Professor of Surgery, Chief, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, Illinois. E-mail: rmilner@lumc.edu