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Ann Thorac Surg 2009;87:416-422. doi:10.1016/j.athoracsur.2008.11.056
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Protocols for Paget-Schroetter Syndrome and Late Treatment of Chronic Subclavian Vein Obstruction

J. Ernesto Molina, MD, PhDa,*, David W. Hunter, MDb, Charles A. Dietz, MDb

a Department of Surgery, Divisions of Cardiothoracic Surgery and Interventional Radiology, University of Minnesota, Medical School, Minneapolis, Minnesota
b Department of Radiology, Divisions of Cardiothoracic Surgery and Interventional Radiology, University of Minnesota, Medical School, Minneapolis, Minnesota

Accepted for publication November 17, 2008.

* Address correspondence to Dr Molina, University of Minnesota, Department of Cardiothoracic Surgery, 420 Delaware St, SE, MMC 207, Minneapolis, MN 55455 (Email: molin001{at}umn.edu).


   Abstract
Top
 Abstract
Part I: The Acute...
 Patients and Methods
 Results (Part I)
 Part II: The Chronic...
 Results (Part II)
 Comment
 References
 
Background: Paget-Schroetter syndrome is a serious condition that if not treated promptly and properly leads to severe sequelae and permanent disability. In its late stage, chronic fibrous obliteration of the vein is rarely amenable to surgical treatment, except in very few select cases.

Methods: We treated 126 Paget-Schroetter syndrome patients (group I) by implementing an emergency protocol of thrombolysis by catheter-directed infusion, followed by immediate surgery through an anterior subclavian approach entailing (1) decompression of the thoracic inlet and (2) repairing the vein with a vein patch to reestablish its normal caliber. In addition, we treated another selective group of 81 patients (group II) for chronic fibrotic obstruction several months after their original event, but only when the inflow was adequate.

Results: Our acute emergency care resulted in a 100% long-term patency rate in group I, with no sequelae. The patency rate in group II was 100% as well, but in 74% a long vein patch, endovascular stents, or homograft implants were used.

Conclusions: Implementation of an emergency approach to treat Paget-Schroetter syndrome is highly recommended to prevent the delayed sequelae of permanent subclavian vein obliteration and disability. In chronic obstruction, when feasible, we recommend a long saphenous vein patch, followed by endovascular stent implant.


   Part I: The Acute Obstruction
Top
 Abstract
 Part I: The Acute...
Patients and Methods
 Results (Part I)
 Part II: The Chronic...
 Results (Part II)
 Comment
 References
 
The spontaneous acute thrombosis of the subclavian vein associated with physical effort is what is called Paget-Schroetter syndrome, or effort thrombosis of the subclavian vein. This is a disease of young people associated with sports or occupations that involve exertional maneuvers done with the arms. Acute pain affects the involved arm, which then swells and sometimes becomes blue. This process progresses within minutes or hours. By the time the person reaches the hospital, significant edema of the arm has already occurred. The diagnosis must be made immediately to provide proper treatment as soon as possible, thereby completely curing the problem and preventing late sequelae [1–9]. The treatment window is very narrow: about 2 weeks. Proper treatment invariably leads to the patient's full recovery when flow through the vein and vein patency are reestablished [10].

Beyond that 2-week window, progressive deterioration of an untreated or improperly treated arm leads to fibrosis of the vein and to extension of the thrombosis into the arm, decreasing significantly the chances for cure and complete recovery as more days pass. By the end of 30 days, the vein usually has already fibrosed, and the edema of the arm becomes chronic. The chances of effective intervention diminish to the point that no surgical intervention can offer any hope of reestablishing the normal venous return flow of the affected arm [11, 12]. This invariably leads to some degree of permanent, irreversible disability of the arm.

The mechanism of thrombosis is now clearly understood [13, 14]. The vein is pinched at the inlet of the thoracic upper aperture between the first rib, the subclavius muscle tendon, and the anterior scalene muscle tendon, all of which form the tunnel through which the vein runs into the chest cavity. At that level, as the vein is pinched (as in a vise), the endothelium is disrupted and the thrombosis begins immediately. With total occlusion of the vein, the clot progresses distally into the axillary vein and the veins of the arm. The patient's preinjury coagulation variables are nearly always normal. Coagulation abnormalities are rare [14]. The syndrome is basically a mechanical trauma to the vein that injures the endothelium, and thrombosis is the normal response of the body to such an insult.

During the past 20-plus years, it has been very clearly established that the treatment of choice is catheter-directed thrombolytic therapy, using any of the currently available thrombolytic agents (Table 1). Nowadays, it is unacceptable to treat these patients only with anticoagulation agents (namely, heparin or warfarin) if no other intervention is planned. The current standard of care mandates thrombolytic therapy first, followed immediately by decompression of the thoracic inlet and reestablishment of the normal subclavian vein caliber.


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  		Table 1 Various Thrombolytic Agents and Doses Commonly Used for the Thrombolytic Stage of the Treatment of the Acute Paget-Schroetter Syndrome
 
We have previously reported our work during the past 25 years of treating Paget-Schroetter syndrome patients with a standard protocol of care implemented during the acute stage [10]. The three basic steps are:
1 After the workup has established thrombosis, we begin thrombolytic therapy by catheter-directed infusion in the clot until it is dissolved.
2 Immediately afterward, we surgically decompress the thoracic inlet and perform direct vein patch angioplasty of the affected vessel, which invariably has a fibrotic stenosis at the site of the occlusion.
3 Then we prescribe anticoagulation therapy for 8 weeks, after which the typical patient is considered cured.

These 3 steps have been published by our institution [4, 10, 15] and have proven to be 100% effective.


   Patients and Methods
Top
 Abstract
 Part I: The Acute...
 Patients and Methods
Results (Part I)
 Part II: The Chronic...
 Results (Part II)
 Comment
 References
 
From July 1985 through May 2008, we treated 126 patients (69 men, 57 women) with our emergency protocol (Group I). The mean patient age was 28.9 ± 3.7 years. The right arm was more frequently involved; 76% of the patients were right-handed. In the subgroup of patients injured in sports, the activities varied widely, including swimming, tennis, weightlifting, climbing, volleyball, baseball pitching, and others. In the subgroup injured at work, the occupations included construction workers, mechanics, tree trimmers, and loaders of trucks.

The thrombolytic therapy was implemented with tenecteplase (TNK; Genentech, South San Francisco, CA) at an hourly infusion of 0.05 mg/kg (mean, 0.25 mg/h). Successful lysis of the clot occurred within 24 hours; for some, within 2 hours. During thrombolytic therapy, the patient returned to the interventional radiology suite for repeated venograms to verify total lysis of the clot and demonstrate the exact extent of the obstruction. The details of this technique can be seen in our previous reports [10, 15].

Operative Procedure
The operation has been previously described [4, 10, 15, 16]. It consists of two components: decompression of the thoracic inlet and reestablishment of the vein patency and caliber. The technique involves an anterior subclavicular approach to the first rib, removal of its anterior portion, and removal of the subclavius tendon and costoclavicular ligament, with transection of the anterior scalene muscle. This is all done from an extrapleural approach by detaching the inferior periosteum of the first rib. Then the subclavian vein is dissected and detached from the posterior aspect of the sternum and the stump of the first rib until the entire vein can be mobilized and brought into the field.

It is of utmost importance to dissect the vein more medially in order to reach normal vein in its innominate portion so that a patch of saphenous vein can be laid across the stenotic portion. Doing so reestablishes the normal diameter of the vein, from the normal axillary vein to the normal innominate vein [4]. This is the crucial part of the operation. If it is not done properly, that is, if the patch is not extended to the normal innominate vein, residual obstruction or occlusion may occur in the immediate postoperative period.

Anticoagulation is begun the evening of the procedure (Table 2) and continued with warfarin and clopidogrel for 8 weeks to keep an international normalized ratio between 2 and 3.


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  		Table 2 Anticoagulation Regimen II Followed in the Postoperative Period
 
We routinely obtain an ultrasound study the day after the operation to check the flow of the vein as well as its caliber. If we have any doubt, we clarify the anatomy of the vein with a venogram. In case of residual stenosis, the patient undergoes balloon angioplasty of that segment along with implantation of a stent. If a stent is implanted, warfarin therapy is extended to 3 months instead of 2 months.

We leave an extrapleural drain, usually a size 19 Jackson-Pratt connected to bulb suction. After the second or third day, when the amount of drainage for 24 hours does not exceed 30 mL total, we remove the drain and discharge the patient.


   Results (Part I)
Top
 Abstract
 Part I: The Acute...
 Patients and Methods
 Results (Part I)
Part II: The Chronic...
 Results (Part II)
 Comment
 References
 
Of our 126 patients, all 126 (100%) had a patent vein at a follow-up of 6 months to 25 years (66 of them are beyond 5 years). All 126 resumed normal activities, including sports or their occupations. No patient has any restrictions in the random movement of the arm or any diminishment in muscle strength.

During the follow-up period, clopidogrel was discontinued in 3 patients because of intolerance, and they remained only on warfarin.


   Part II: The Chronic Obstruction
Top
 Abstract
 Part I: The Acute...
 Patients and Methods
 Results (Part I)
 Part II: The Chronic...
Results (Part II)
 Comment
 References
 
All patients with chronic obstruction of the subclavian vein are symptomatic if not at rest, and certainly when they physically exert the involved arm. Almost all patients became disabled, at least in terms of physical activity with that arm. A significant number have to wear continuous compressive elastic devices to suppress arm edema. At that stage, unfortunately, only a few patients are potential candidates for a procedure that will solve the problem, because with time, inflow becomes inadequate.

Physicians, therefore, should be fully aware of three situations in particular, that without timely and proper treatment, can result in chronic obstruction of the subclavian as well as the axillary or even the innominate vein [1]. Most patients with chronic obstruction of the subclavian vein initially had Paget-Schroetter syndrome. Either they were never properly diagnosed, or if they were, timely and proper care was not provided [2]. Some patients were treated with thrombolytic therapy, but were then underwent faulty or ineffective surgical decompression of the thoracic inlet, without reestablishment of the proper caliber of or flow through the subclavian vein. A common culprit is transaxillary resection of the first rib, an approach that usually fails [3].

Some patients treated with thrombolytic therapy undergo implantation of endovascular stents, without surgical decompression of the thoracic outlet. The vein invariably occludes again, creating a worse situation than the original one because the stent cannot be removed once implanted [17–20]. Also, if a stent is placed after a transaxillary resection of the first rib, the stent often kinks over the residual rib stump, it fails, and the vein occludes again.

Once fibrosis sets in, the walls of the vein become very thick, until the entire vein, with or without a previously implanted stent, becomes a fibrous cord, totally obliterated, with no lumen. The only hope for such patients is surgical intervention, but that may only be feasible under very specific circumstances.

Of our 81 patients with chronic obstruction (Group II) who were selected for an operation, 49 had a short segment (<2 cm) of obstruction; 32, a long segment (3 to >20 cm). The few patients with a long segment (20 cm) had fibrosis that extended from the subclavian vein to the axillary and brachial vein as well. Of those, 4 had already undergone operations elsewhere. Even though they had initially undergone the correct thrombolytic treatment, their procedure was not performed immediately and did not use the subclavicular approach. Instead, the transaxillary route was used, which failed to reestablish the proper caliber of the vein and required implantation of endovascular stents. This second maneuver did not solve the problem either, because the stent invariably kinked over the residual first rib stump that was left anteriorly. In 2 of those 4 patients, the stent broke at that level. In all 4, the vein occluded again. Months after their operation, they were seen at our institution. Three other patients had additional stents placed before being referred to our institution.

The 49 patients with a short segment of chronic obstruction underwent our standard operation. However, 5 (10%) showed residual stenosis on venograms the day after the procedure and an endovascular stent was implanted.

The 32 patients with a long segment of obstruction all required a transsternal extension [10, 21] of the subclavicular incision to expose the proximal innominate vein. Then, we either replaced the venous segment using a pediatric-sized thoracic aortic homograft or, in recent years, used a very long venous patch, followed by implantation of a long endovascular stent. We obtained a venogram the day after the operation in all 32 patients. The interventional radiologist, early postoperatively can pass a guidewire through the operated segment, even if it has reclotted, and can declot and stent the segment to reestablish normal flow. For our patients who underwent thoracic aortic homograft implantation, we obtained a venogram at periodic intervals. If the homograft showed signs of stenosis (Fig 1), which sometimes was very severe, it was treated with dilation and implantation of an endovascular stent.


Figure 1
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  		Fig 1. A pediatric descending aorta homograft was implanted in a 38-year-old man. (A) At 11 months after implantation, the homograft segment shows uniform development of stenosis. (B) After balloon dilation and implant of an endovascular stent.

 
Surgical Options
Most of the time, chronic obstruction of the subclavian vein involves long segments, usually 3 to 7 cm or even longer (Fig 2). But sometimes the obstruction remains rather short (≤2 cm; Fig 3). If the obstruction shown by venogram is short, then the standard operation as in Group I for the acute event should be 100% effective, reestablishing the normal caliber and flow of the subclavian vein. If the operation is done correctly, stents are usually not needed.


Figure 2
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  		Fig 2. A venogram showed a long (8.3-cm) fibrous stenotic segment of the subclavian vein after thrombolytic therapy was completed.

 

Figure 3
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  		Fig 3. A 25-year-old woman presented with a short segment of stenosis that was caused by her occupation, which was carrying heavy objects.

 
Few options are available if the operation involves a long segment. We either replace the entire obstructed segment (as we have previously reported) [21–23] or use a long venous patch, followed by stent implantation. Both of these options, however, can only be successful if the inflow coming from the arm is adequate, which means that the axillary vein must be at least 1 cm in diameter, hopefully larger, and that no extensive network of collaterals exists. If the inflow is not adequate, any surgical attempt will fail. Any stent implantation must be preceded by proper inlet decompression, which, as already stressed, should be through a subclavicular, anterior—but not transaxillary—approach.

Vein Substitution
Currently, no adequate prosthetic tubular grafts will stay open to replace a vein in the subclavian position. We reported in 1999 [23] the use of small-caliber aortic homografts, obtained from the descending thoracic aorta of deceased pediatric donors. Such grafts are usually 10 to 12 mm in diameter, closely matching the normal caliber of an adult subclavian vein. The disadvantage is that the grafts eventually become calcified and need to be dilated (Fig 1). Stent implantation is commonly needed to keep the grafts open because they also tend to narrow with time, usually during the first or second year after implantation.

The second option is to use a long, upper thigh saphenous vein patch to connect the axillary vein to the innominate vein. Doing so reestablishes the continuity of the channel, through which, on the next day, the radiologist can pass a guidewire and implant a stent of the proper caliber (Fig 4). The flow and the caliber of the vein are thus reestablished. We now prefer this approach, given the homograft problems of calcification, reobstruction, and high cost.


Figure 4
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  		Fig 4. A 32-year-old man with a long segment of stenosis was treated with an extended saphenous vein graft that reclotted at 24 hours and was treated with an endovascular stent, which has kept the vein patent for 2 years.

 
Operative Procedure for Vein Patch Placement
Our experience during the last 20 years has demonstrated the effectiveness of the subclavicular approach. It allows complete exposure of the subclavian vein and of the structures causing compression at the thoracic inlet. With a long segment of chronic obstruction, the standard incision often needs to be extended into the manubrium of the sternum, as we previously described [22, 24]. After removing the anterior half of the first rib, a Neurairtome (Zimmer Inc, Warsaw, IN) is used to cut through the stump of the first rib to the center of the manubrium of the sternum. It is turned at a right angle vertically to cut to the sternal notch in order to open the space and expose the entire innominate vein (24). With this exposure, it is very easy to lay a long saphenous vein graft from the innominate to the axillary vein (Fig 5A, B).


Figure 5
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  		Fig 5. (A) A 39-year-old man presented with a chronic, long segment of obstruction of the subclavian vein (8.3 cm). Dotted line indicates the length of the stenotic segment after thrombolysis. (B) Postoperative result using a transsternal incision to lay a long saphenous vein patch shows normal flow and caliber of the subclavian vein.

 
The closure of the incision involves the use of 2 stainless steel wires, putting the manubrium of the sternum back together to maintain the stability of the chest wall (Fig 6). There is never any need to divide the clavicle or to use multiple wires to repair the sternal cut. However, it is critical to immobilize the arm in a sling for at least 6 weeks until the manubrium is completely healed to prevent dehiscence.


Figure 6
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  		Fig 6. Drawing shows the placement of 2 sternal wires sutures (6 or 8 gauge) to repair the sternotomy portion of the incision (p = saphenous vein patch; Scl = subclavian vein).

 
The next morning, the patient is taken to the interventional radiology suite for a venogram and for implantation of a stent if needed involving the entire length of the implanted patch. This is a very important step. The vein commonly rethrombosis again by the next day, despite the patch, because of the tremendous vein wall fibrosis, which is rigid and tends to close down the venous channel. The main purpose of the patch is to connect both ends of the vein and provide a conduit through which the interventional radiologist can pass the guidewire, after which stent implantation is relatively easy. Afterward the patient is maintained on anticoagulants for 3 months (Table 2). We have not seen any advantage of anticoagulants beyond 3 months. The patient undergoes an ultrasound examination before being discharged home and again at 2 weeks, 1 month, and 3 months.


   Results (Part II)
Top
 Abstract
 Part I: The Acute...
 Patients and Methods
 Results (Part I)
 Part II: The Chronic...
 Results (Part II)
Comment
 References
 
As explained previously only the patients whose axillary vein was larger than 1 cm in diameter, with adequate inflow and caliber, underwent surgical intervention. Of the 49 patients with a short segment of chronic obstruction, 44 required only the saphenous vein patch, which remained patent with good flow and caliber postoperatively. The patency rate was 100%. The other 5 patients (10%) with residual stenosis underwent implantation of a stent. Their patency rate was also 100% from 2 to 18 years, with 3 patients beyond 5 years.

Of the 32 patients with a long segment of chronic obstruction, 14 (subgroup A) were initially treated with implantation of thoracic aortic homografts. Of those 14 grafts, 10 (71%) remain patent beyond 5 years. In the other 4 patients, reobstruction occurred and required balloon dilation and implantation of a stent 7 to 18 months postoperatively (Fig 1). Only 2 patients are beyond 5 years with a patent vein.

The other 18 patients (subgroup B) were treated with our current long vein patch protocol. Reclotting of the vein occurred the day after the procedure in 11 patients, and they underwent implantation of a long endovascular stent. Included were 3 patients who had previously undergone transaxillary resection of the first rib, followed by stent implantation. They all have remained patent from 6 months to 4 years.

The patients who had previously undergone transaxillary resection of the first rib elsewhere underwent our standard substernal, anterior operation. We found all of them had residual anterior first rib stumps (1.5 to 2 inches long). They all also had intact subclavius tendons and intact costoclavicular ligaments that had not been resected during the transaxillary operation. Our anterior approach allowed us to remove the remaining rib stumps, ligaments, and subclavius tendons and to leave the vein completely free and without any kinks. The patency rate for these 18 patients was 95%. Our 1 failure was in a patient with multiple endovascular stents that had been previously implanted elsewhere. The other 7 are patent from 8 months to 3 years and have not required stent placement (Fig 5).


   Comment
Top
 Abstract
 Part I: The Acute...
 Patients and Methods
 Results (Part I)
 Part II: The Chronic...
 Results (Part II)
 Comment
References
 
It is very clear to us, looking at our and other investigators' experience, that the standard of care for acute obstruction of the subclavian vein is catheter-directed thrombolytic therapy, followed immediately by surgical intervention using an anterior subclavicular approach. With this protocol, the long-term patency rate is 100%, with no sequelae and with full return of patients to their normal preinjury activities. To obtain these results, however, the patient must be properly diagnosed and promptly treated to prevent progression of the fibrosis that is invariably irreversible unless we intervene.

If the patient is not correctly and promptly treated, the normal use of that arm is permanently lost. Very few patients with chronic obstruction of the subclavian vein after an injury several months previously are candidates for operation (81 in this series). Most cannot be helped surgically and will have from some degree of edema and pain for life.

Many vascular surgeons are applying an operation that is not optimal for this condition. The transaxillary resection of the first rib, introduced by Roos in 1966 [25], was meant to solve compression of the brachial plexus and of the subclavian artery, not of the subclavian vein. The vein occupies the most anterior portion of the upper aperture of the chest. As we have frequently seen, the transaxillary approach is not adequate for relieving compression of the subclavian vein [26, 27]. With the transaxillary approach, the surgeon invariably leaves the costoclavicular ligament and the subclavius tendon intact, as well as a significant rib stump anteriorly where the vein or the stent becomes kinked. The proper steps can only be accomplished with the anterior approach [28]. The transaxillary route should be completely abandoned for treating effort thrombosis patients.


   References
Top
 Abstract
 Part I: The Acute...
 Patients and Methods
 Results (Part I)
 Part II: The Chronic...
 Results (Part II)
 Comment
 References
 

  1. Langley DG, Yedlicka JW, Molina JE, et al. Thoracic outlet syndrome: Evaluation of the subclavian vessels by color duplex sonography Am J Rad 1992;158:623-640.
  2. Adams JT, DeWeese JA. "Effort" thrombosis of the axillary and subclavian veins J Trauma 1971;11:923-930.[Medline]
  3. Drapanas T, Curran WL. Thrombectomy in the treatment of "effort" thrombosis of the axillary and subclavian veins J Trauma 1966;6:107-119.[Medline]
  4. Molina JE. Surgery for effort thrombosis of the subclavian vein J Thorac Cardiovasc Surg 1992;103:341-346.[Abstract]
  5. Zimmerman R, Morl H, Harenberg J, et al. Urokinase therapy of subclavian-axillary vein thrombosis Klin Wochenschr 1981;59:851-856.[Medline]
  6. Azakie A, McElhinney DB, Thompson RW, et al. Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression J Vasc Surg 1998;28:777-786.[Medline]
  7. Aziz S, Straehley CJ, Wheland Jr TJ. Effort-related axillosubclavian vein thrombosis. A new theory of pathogenesis and a plea for direct surgical intervention. Am J Surg 1986;152:57-61.[Medline]
  8. Schneider DB, Dimuzio PJ, Martin ND, et al. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty J Vasc Surg 2004;40:599-603.[Medline]
  9. Kreienberg PB, Chang BB, Darling RC, et al. Long-term results in patients treated with thrombolysis, thoracic inlet decompression, and subclavian vein stenting for Paget-Schroetter syndrome J Vasc Surg 2001;33(suppl II):100-105.
  10. Molina JE, Hunter DW, Dietz CA. Paget-Schroetter syndrome treated with thrombolytics and immediate surgery J Vasc Surg 2007;45:328-334.[Medline]
  11. Swinton Jr NW, Edgett JW, Hall RJ. Primary subclavian-axillary vein thrombosis Circulation 1968;38:737-745.[Abstract/Free Full Text]
  12. Hughes JP, Ochsner JL, Sartor DW. Surgical treatment of primary thrombosis of the subclavian-axillary vein J Louisiana State Med Soc 1974;126:77-79.
  13. McCleery RS, Kesterson JE, Kirtley JA, Love RB. Subclavius and anterior scalene muscle compression as a cause of intermittent obstruction of the subclavian vein Ann Surg 1951;133:588-602.[Medline]
  14. Martinelli I, Battaglioli T, Bucciarelli P, et al. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities Circulation 2004;110:566-570.[Abstract/Free Full Text]
  15. Molina JE. Need for emergency treatment in subclavian vein effort thrombosis J Am Coll Surg 1995;181:414-420.[Medline]
  16. Wilson JJ, Zahn CA, Newman H. Fibrinolytic therapy for idiopathic subclavian-axillary vein thrombosis Am J Surg 1990;159:208-211.[Medline]
  17. Meier GH, Pollak JS, Rosenblatt M, et al. Initial experience with venous stents in exertional axillary-subclavian vein thrombosis J Vasc Surg 1996;24:974-983.[Medline]
  18. Bjarnason H, Hunter DW, Crain MR, et al. Collapse of a Palmaz stent in the subclavian vein Am J Radiol 1993;160:1123-1124.[Free Full Text]
  19. Hammer F, Becker D, Coffette P, et al. Crushed stents in benign left brachiocephalic vein stenosis J Vasc Surg 2000;32:392-396.[Medline]
  20. Urschel Jr HC, Patel AN. Paget-Schroetter syndrome therapy: failure of intravenous stents Ann Thorac Surg 2003;75:1693-1696.[Abstract/Free Full Text]
  21. Molina JE. Treatment of chronic obstruction of the axillary, subclavian, and innominate veins Intl J Angiol 1999;8:87-90.
  22. Molina JE. A new surgical approach to the innominate and subclavian vein J Vasc Surg 1998;27:576-581.[Medline]
  23. Molina JE. Use of cryopreserved small aortic homografts for large vein replacement Vasc Surg 1999;33:545-555.
  24. Molina JE. Approach to the confluence of the subclavian and internal jugular veins without claviculectomy Semin Vasc Surg 2000;13:10-19.[Medline]
  25. Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet syndrome Ann Surg 1966;163:354-358.[Medline]
  26. Hall LD, Murray JD, Boswell GE. Venous stent placement as an adjunct to the staged, multimodal treatment of Paget-Schroetter syndrome J Intervent Radiol Rounds 1995;6:565-570.
  27. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: Spontaneous thrombosis of the axillary-subclavian vein J Vasc Surg 1993;17:305-317.[Medline]
  28. Molina JE. Operative technique of first rib resection via subclavicular approach Vasc Surg 1993;27:667-671.

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