title: Acute Paget-Schroetter syndrome: does the first rib routinely need to be removed after thrombolysis?
abstract: BACKGROUND
  Most clinicians feel that treatment for patients with acute primary axillosubclavian vein thrombosis ("effort thrombosis") is catheter-directed thrombolysis followed by thoracic outlet decompression. Several investigators feel that first rib resection (FRR) is not indicated in every case. No randomized data exist to answer this question.
  
  
  METHODS
  A MEDLINE search was done using the terms "Paget-Schroetter syndrome," "upper extremity DVT," "first rib resection," "effort thrombosis," and "primary upper extremity thrombosis," with thrombolysis used as an "AND" term. We also specifically explored references cited to support either side of this argument in the past. Analysis was limited to patients aged 18 years or older with symptoms of 14-day duration or less undergoing thrombolysis for primary axillosubclavian vein thrombosis. Those studies that did not report follow-up, duplicate series from the same institution, and those in which patients were stented were excluded. Results were analyzed on an intent-to-treat basis, with groups assigned according to each authors' prospectively described algorithm.
  
  
  RESULTS
  Twelve series were included. Patients were divided into 3 groups according to treatment after thrombolysis: FRR (448 patients), FRR plus endovenous balloon venoplasty (FRR + PLASTY; 68 patients), and those with no further intervention after thrombolysis (rib not removed; 168 patients). Symptom relief at last follow-up was significantly more likely in the FRR (95%) and FRR + PLASTY (93%) groups than in the rib not removed (54%) group (both <0.0001) as was patency (98%, 86%, and 48%, respectively; both <0.0001 vs. rib not removed). More than 40% of patients in the rib not removed group eventually required rib resection for recurrent symptoms. No differences in symptom-free rates were seen when comparing FRR with FRR + PLASTY.
  
  
  CONCLUSIONS
  In patients with acute effort thrombosis who undergo thrombolysis, permanent symptom relief and long-term patency are more likely to be achieved in patients who undergo FRR with or without endovenous balloon venoplasty than those whose rib is left intact.
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Joanelle
authors.initials: J
authors.lastname: Lugo
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Adam
authors.initials: A
authors.lastname: Tanious
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Paul
authors.initials: P
authors.lastname: Armstrong
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Martin
authors.initials: M
authors.lastname: Back
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Brad
authors.initials: B
authors.lastname: Johnson
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Murray
authors.initials: M
authors.lastname: Shames
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Neil
authors.initials: N
authors.lastname: Moudgill
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL.
authors.forename: Peter
authors.initials: P
authors.lastname: Nelson
authors.affiliation: Division of Vascular Surgery, University of South Florida, Tampa, FL. Electronic address: killig@health.usf.edu.
authors.forename: Karl A
authors.initials: KA
authors.lastname: Illig
mesh_terms: D000208:Acute Disease; D000800:Angioplasty, Balloon; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D019299:Decompression, Surgical / Q000009:adverse effects / Q000379:methods*; D018572:Disease-Free Survival; D006801:Humans; D010027:Osteotomy / Q000009:adverse effects; D010690:Phlebography / Q000379:methods; D012272:Ribs / Q000601:surgery*; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000009:adverse effects; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D056824:Upper Extremity Deep Vein Thrombosis / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D014654:Vascular Patency