DOI:10.2214/AJR.06.0028
AJR 2007; 188:1215-1217
© American Roentgen Ray Society
Power-Pulse Spray Thrombectomy for Treatment of Paget-Schroetter Syndrome
Ami D. Shah1,
Danielle R. Bajakian2,
Jeffrey W. Olin3 and
Robert A. Lookstein1
1 Department of Interventional Radiology, Mount Sinai School of Medicine, Mount
Sinai Medical Center, One Gustave L. Levy Pl., Box 1234, New York, NY
10029.
2 Department of Vascular Surgery, Mount Sinai School of Medicine, Mount Sinai
Medical Center, New York, NY.
3 Department of Vascular Medicine, Mount Sinai School of Medicine, Mount Sinai
Medical Center, New York, NY.
Received January 8, 2006;
accepted after revision November 21, 2006.
Address correspondence to R. A. Lookstein
(robert.lookstein{at}msnyuhealth.org).
Abstract
OBJECTIVE. This initial single-center study describes three cases of
axillary-subclavian vein thrombosis (Paget-Schroetter syndrome) treated with a
rapid, novel thrombectomy technique, termed "power-pulse spray
thrombectomy," in which a thrombolytic agent is directly infused into
the clot via a catheter, followed by intravascular mechanical clot fracture
and removal.
CONCLUSION. All patients in this series were treated in a single
session. Complete clot removal was successfully achieved without the
development of any complications. This is the first description of the
application of this technique in the treatment of Paget-Schroetter syndrome to
our knowledge.
Keywords: Paget-Schroetter syndrome • thrombolysis • venography
Introduction
Paget-Schroetter syndrome, also known as "effort"
thrombosis of the axillary-subclavian vein, is a condition that tends to occur
in young, active, otherwise healthy individuals and is characterized by the
acute onset of swelling in the upper extremity. Often, it is precipitated by
trauma or strenuous exercise. Other associated symptoms include pain; venous
distention over the chest, arm, or hand; paresthesias; bluish-red
discoloration; coolness to touch; and tenderness or palpable cords over the
basilic and axillary veins
[1-3].
Although the condition was once thought to be an acute, low morbidity
disorder, its capacity for significant long-term sequelae is now widely
recognized. The degree of disability that can result is compounded by the
young age and generally healthy status of the population it afflicts. Late
complications include a postthrombotic syndrome characterized by recurrent
episodes of pain, swelling, and superficial thrombophlebitis and chronic
venous insufficiency secondary to venous hypertension and valvular damage
[1,
2]. Pulmonary embolism and rare
cases of phlegmasia cerulea dolens have also been reported
[1].
The current standard of care for treating Paget-Schroetter syndrome
involves catheter-directed thrombolysis followed by surgical decompression
with resection of the ipsilateral first rib. Although this technique
effectively addresses the acute symptoms and reduces the frequency of
long-term sequelae, it requires a long lysis time with multiple visits to the
angiography suite and has been associated with complications that include
intracerebral hemorrhage, pulmonary embolism, and access site bleeding
requiring transfusion [4]. In
this article, we describe the application of a rapid pharmacomechanical
thrombolysis technique, termed "power-pulse spray thrombectomy,"
to the treatment of Paget-Schroetter syndrome to more rapidly debulk thrombus.
Power-pulse spray thrombectomy has previously been described by Allie et al.
[5] in the treatment of acute
limb ischemia due to iliofemoral arterial thrombosis. This single-center
initial clinical experience is the first reported application of this
technique in the treatment of Paget-Schroetter syndrome to our knowledge.
Materials and Methods
In this series, three consecutive patients who presented to our emergency
department with symptoms of Paget-Schroetter syndrome were taken to the
vascular laboratory where thrombosis was confirmed by duplex sonography. The
patients were then referred to the angiographic suite for venography. The
ipsilateral brachial vein was accessed using sterile micro-puncture technique
under sonographic guidance. A 6-French vascular sheath was placed into the
brachial vein, and venography was performed to delineate the extent of the
thrombus. The brachial, axillary, and subclavian veins were visualized. A
4-French directional catheter and a steerable hydro-philic glidewire were used
to cross the intraluminal thrombus and were placed into the brachiocephalic
vein. A 6-French Xpeedior AngioJet rheolytic thrombectomy catheter (Possis
Medical) was then advanced through the thrombosed axillary-subclavian vein.
The AngioJet catheter system allows for both the infusion of thrombolytic
agents directly into a clot and mechanical clot removal. Mechanical
thrombectomy is facilitated by high-velocity saline jets at the catheter tip
that create rapid fluid streaming and hydrodynamic forces that fracture the
thrombus and allow its extraction through the aspiration port of the catheter
by means of negative pressure (Bernoulli Venturi principle).
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Fig. 1A —22-year-old athletic woman who underwent power-pulse spray
thrombectomy. Initial venogram from left brachial vein sheath shows absence of
flow in left axillary vein (arrow). Collaterals are preferentially
draining arm from cephalic vein (arrowhead).
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Fig. 1B —22-year-old athletic woman who underwent power-pulse spray
thrombectomy. With catheter in left subclavian vein, venogram shows complete
thrombosis of axillary and subclavian vein (arrow).
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Fig. 1C —22-year-old athletic woman who underwent power-pulse spray
thrombectomy. Completion venogram shows complete resolution of venous
thrombosis. There is residual venous spur (arrow) at anatomic
"pinch off" of subclavian vein between clavicle and first rib.
Small residual thrombus is seen in cephalic vein (arrowhead). This
procedure took 2.5 hours to complete.
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The power-pulse spray technique was performed using tissue plasminogen
activator (t-PA) (Altepase, Genentech). The t-PA solution (20 mg of 1 mg/mL
t-PA added to 50 mL of normal saline) was instilled through the AngioJet
catheter intraluminally while retracting the catheter steadily through the
clot back into the sheath. During the instillation of all 20 mg of the lytic
agent, the aspiration port of the catheter was clamped using a flow switch.
The t-PA solution was allowed to remain in the thrombus for 45 minutes. The
AngioJet catheter was then used in the standard fashion as outlined by the
manufacturer's protocol for percutaneous thrombectomy. A maximum of four
passes were made through the thrombosed regions in each patient.
Postthrombectomy venography was used to evaluate treatment, with balloon
angioplasty using a 10-mm angioplasty balloon to remove any residual
thrombosis or venous spurs. All patients in this series were heparinized
during the procedures, with the administration of IV heparin to maintain
activated partial thromboplastin times in the range of 60-90 seconds. This
protocol was approved by the institutional review board before
implementation.
Results
Case 1
A 21-year-old man who is a concert violinist presented with acute onset of
pain and swelling of the right upper extremity. On examination, the patient
had dilated veins over the anterior chest wall and arm, marked right arm
swelling, cyanosis of the hand, and palpable pulses. Duplex sonography
revealed acute thrombosis of the right axillary-subclavian vein. After
power-pulse spray pharmacomechanical thrombectomy and venous balloon
angioplasty, the patient's symptoms resolved and his veins were widely patent
on follow-up duplex sonography. The total procedure time was 2 hours, with no
postprocedural bleeding complications. Coumadin (warfarin sodium,
Bristol-Myers Squibb) was administered for anticoagulation, and the patient
was discharged on postprocedure day 2. As recommended by the vascular surgeon,
the patient returned 3 weeks later and underwent successful first rib
resection. Forty-eight hours after surgery, anticoagulation with Coumadin was
reinstated, and 1 month later the patient was able to return to playing the
violin.
Case 2
A 22-year-old woman who is a tennis player presented with left arm swelling
and pain after strenuous exercise. On examination, her left arm was markedly
swollen, but her pulses were palpable. Doppler sonography showed extensive
multifocal thrombus of the left axillary-subclavian vein. This was confirmed
by venography (Figs. 1A and
1B). Significant stenosis was
also apparent in the mid subclavian vein on abduction. The patient was treated
with power-pulse spray mechanical thrombectomy followed by balloon angioplasty
to eliminate residual thrombus. The total procedure time was 2.5 hours with no
postprocedural complications. The patient was given heparin before, during,
and after the procedure. The next morning her symptoms were much improved and
duplex venography showed a widely patent vein with the arm adducted, but some
stenosis was apparent on abduction (Fig.
1C). The patient was discharged on postprocedure day 2 on oral
anticoagulants and, at the vascular surgeon's preference, she returned 10 days
later for first rib resection.
Case 3
An otherwise healthy 44-year-old woman, referred from an outside hospital,
presented with the sudden onset of left upper extremity swelling and mild
cyanosis. Duplex sonography at the outside hospital and CT venography at our
institution confirmed the presence of thrombosis in the left
axillary-subclavian vein. The patient promptly underwent power-pulse spray
mechanical thrombectomy followed by balloon angioplasty for residual
thrombosis. The total procedure time was 2 hours 10 minutes. Postprocedural
venography showed normal filling of the vein with the arm in the anatomic
position, but persistent narrowing on abduction with no visualization of
collateral flow. Her postoperative course was uncomplicated. The patient was
discharged on postprocedure day 2 on oral anticoagulation. The patient
underwent successful first rib resection 2 weeks after the thrombectomy.
At 1-year follow up, all patients in this series had full function of their
arms, no residual symptoms, and no reoccurrence of deep venous thrombosis.
Discussion
The primary objectives of treatment of Paget-Schroetter syndrome are relief
of acute symptoms, restoration of flow, and prevention of recurrence and
long-term complications. To achieve these goals, treatment techniques have
evolved over time. Early treatments were conservative, primarily involving
rest, arm elevation, and anticoagulation, with surgery reserved for symptom
recurrence [1,
6].
Although conservative therapies were effective in treating acute symptoms,
their long-term success rates were limited. In one study by Adams and DeWeese
[1], of 28 patients undergoing
conservative treatment, 12% suffered pulmonary embolism; 18% had venous
distention; and 70% had residual symptoms of swelling, pain, and superficial
thrombophlebitis at follow-up
[1]. Such dismal results led to
the development of more aggressive therapies, including thrombectomy and
surgical decompression as adjuvants to anticoagulation
[1].
Since 1980, the use of catheter-directed thrombolysis followed by first rib
resection and neurovascular decompression has become the standard of care.
This approach has reduced the necessity for thrombectomy and its associated
complications of proximal venous control, air embolism, bleeding, and brachial
plexus injury [7]. After
surgical decompression, clots that failed to lyse completely with
thrombolytics tended to lyse spontaneously or recanalize
[7].
Although catheter-directed thrombolysis with surgical decompression does
offer significantly better results compared with conservative treatments, it
is both costly and labor intensive, requiring multiple visits to the
angiography suite and monitoring in step-down or intensive-care facilities
during the period of thrombolysis, which can last from 1 to 3 days
[7,
8]. Moreover, both major and
minor complications of catheter-directed thrombolysis as a treatment for deep
venous thrombosis have been reported at rates of 4.9% and 7.3%, respectively
[4].
In this article, we have presented three cases of Paget-Schroetter syndrome
treated with a novel interventional technique, power-pulse spray
pharmacomechanical thrombectomy. By using a combination of mechanical and
pharmacologic thrombolysis, this technique reduces lysis time to a period of
2-3 hours, which can be completed during a single visit to the angiography
suite. All patients in this series were successfully treated in a single
session, with complete removal of thrombus from the deep venous system and
without any complications.
Although risk of pulmonary embolism secondary to clot removal is a valid
theoretic concern, the previous protocol at our institution for
catheter-directed thrombolysis did not require any aggressive preventive
measures, such as the placement of a temporary superior vena cava filter
before the procedure. When adapting this protocol for the power-pulse spray
technique, we thought that use of the AngioJet catheter did not necessitate
additional precautions with respect to pulmonary embolism. None of the
patients in this series had clinical evidence of pulmonary embolism during or
after the procedures.
One of the shortcomings of this study is the difficulty in quantifying the
relative effects of t-PA infusion compared with mechanical thrombectomy on
clot lysis. Additional studies comparing pharmacologic lysis to mechanical
lysis are warranted to more fully characterize the benefits of the combined
pharmacomechanical approach. In addition, this initial single-center study is
limited by the small number of patients. Despite these limitations, we hope
that this report will stimulate further studies to clarify the role of the
power-pulse spray technique in the treatment of upper extremity venous
thrombosis secondary to Paget-Schroetter syndrome.
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Abstract
Introduction
