Ann Thorac Surg 2009;87:422. doi:10.1016/j.athoracsur.2008.11.058
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Joseph Rubin, MD, CM
22 River Reach Way, Charleston, SC 29407-3372
(Email: jrubin{at}knology.net).
Molina and colleagues [1] continue to expand their already extensive experience with their well-defined protocol for managing Paget-Schroetter syndrome. At first glance many will conclude, albeit superficially, that this article is a potboiler, but only until the reader looks closely at the number of patients in the series and the near perfect patency rates of the subclavian vein in their 126 subjects 6 months after intervention.
Dozens of articles have been published in the past 10 years on the subject of effort thrombosis of the upper extremity. If there is any consensus, most would agree with the University of Minnesota approach as Molina and colleagues [1] have explained. There is the expected small collection of reports advocating nonoperative intervention, and yet others who maintain that the transaxillary approach is superior to the anterior subclavian approach. In response to their critics Molina and colleagues [1] enunciate the principles of treatment: decompression of the anterior thoracic inlet and repair of the vein with a vein patch to re-establish its normal caliber. For late diagnosis or previously unsuccessful intervention associated with advance fibrosis of the vein, management is a little less clear, although the authors explain their approach in this scenario with specificity. For a disease that is not common, one series of 126 is an enviable collection and certainly gives leadership and "bragging rights" to the Minnesota group.
As recently as 2004, Khan and Stansby [2] performed a survey of surgeons in the United Kingdom in an attempt to establish consensus in the management of Paget-Schroetter syndrome. Noting that prolonged disability is the outcome of incomplete therapy, they focused on the recent literature advocating active management. Not surprisingly they found no definite consensus on the treatment of this condition in the United Kingdom. A majority favored a multimodal approach. Thrombolysis was the most common form of treatment used, and first rib resection through the transaxillary approach remained the most popular surgical procedure. To Shaukat and Stansby [2], the lack of consensus of this potentially disabling condition highlighted the need for randomized clinical trials to guide management. In my opinion, Molina and colleagues [1] have surpassed the need for a clinical trial because of their extensive experience and the relatively homogenous characteristics of their outcomes at low risk.
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References
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- Molina JE, Hunter DW, Dietz CA. Protocols for Paget-Schroetter syndrome and late treatment of chronic subclavian vein obstruction Ann Thorac Surg 2009;87:416-422.[Abstract/Free Full Text]
- Khan SN, Stansby G. Current management of Paget-Schroetter syndrome in the UK Ann R Coll Surg Engl 2004;86:29-34.[Medline]
Related Article
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Protocols for Paget-Schroetter Syndrome and Late Treatment of Chronic Subclavian Vein Obstruction
- J. Ernesto Molina, David W. Hunter, and Charles A. Dietz
Ann. Thorac. Surg. 2009 87: 416-422.
[Abstract]
[Full Text]
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References