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Ann Thorac Surg 2000;69:1668-1669
© 2000 The Society of Thoracic Surgeons
DR NORMAN J. SNOW (Chicago, IL): Dr Urschel, what do you mean exactly by prompt removal of the first rib after the thrombolysis? Are you talking about hours, days, or a week?
DR. URSCHEL: "Prompt" is a relative term. What we generally do is give them 24 to 48 hours trial of thrombolysis; after 48 hours it is probably not going to open up. You may get a partial opening during that time. We then simply schedule them for surgery the next day. If thrombolysis finishes up in the evening, we operate on them the next morning. We usually leave them on heparin if we do that. If we operate on them in the afternoon, we don’t use heparin.
DR MARK J. KRASNA (Baltimore, MD): Dr Urschel, we are indebted to you in understanding the Paget-Schroetter-Urschel syndrome better than anybody else; you have taught us about it over the years. I must say that ever since I first heard you give a lecture on this topic I keep going back to my thoracic outlet syndrome patients and I look for one case, but haven’t found one yet. I know they are not endemic to Dallas because you have baseball players from all over the country coming to you. Can you tell us, is there a tip-off? Should I be doing a venogram on every thoracic outlet syndrome or is there some other screening method that you are using; I am still looking for one because I’d like to refer it to you.
DR URSCHEL: The place they occur frequently is in college baseball players; this is the most common place. From New Mexico State, we have had six. The largest problem is that physicians don’t usually make the diagnosis. The average doctor in the country does not see many cases. And once he tips to it, most use anticoagulants. They don’t ever think of thrombolysis unless they happen to know an interventional radiologist or some vascular thoracic surgeon, because it just isn’t the way people think. They are slow to make the diagnosis and they are slow to give the thrombolytic agents. For athletes this is a tragedy because the best time is that first few days.
DR KRASNA: Would you do a venogram on all the patients who are athletes who present to you?
DR URSCHEL: We do a venogram because we use that catheter to give them the thrombolytic agents. You insert an antecubital catheter, perform the venogram and then you have your entrance for your thrombolytic therapy. You could make this diagnosis clinically in most every case. They have all these other things, but the venogram simply tells you how long the clot is, how extensive the collateral is, and other kinds of problems that you might have.
DR WILLIAM A. COOK (North Andover, ME): Hal, I know that you have some fairly aggressive interventional radiologists in Dallas, and I am wondering if you have one single case in which an internal self-expanding stent has been placed in the area, and if so, how did that go?
DR URSCHEL: The self expanding stent? That is a disaster. And the problem is, that people who use them don’t understand the pathophysiology–that this is an external compression, and it will not open it up. The stent usually clots and then you really have a problem unless they develop collateral circulation. A stent has no place in the management of this disease. Usually the first thing radiologists think about is the balloon because they see that narrowing. The second thing is the stent, because then you don’t need an operation. Unfortunately they are all doomed to failure and you can’t get that stent out very easily.
The reason that I got interested in thoracic outlet syndrome is because in 1947 I had this problem where if my head were knocked to the right, my arm would go numb for about three days. They sent me down to Dr George Bennett at Johns Hopkins. He had operated on Joe DiMaggio. He said, you have a cervical rib, your vein is narrowed, your artery is narrowed. You need an operation or a brace. So of course I took the brace, "surgery is for others."
They put this piece of steel on my shoulder pad and covered it with leather. With no face masks we would knock noses off and teeth out. The brace was outlawed by the NCAA who gave me the first "doughnut," which most linebackers now use. Using the single wing formation I was a running guard. Our team had the last Heisman Trophy winner and the last "Coach of the Year" from the Ivy League.
Over 50-some years, Churchill was interested in it, and Dr DeBakey wrote a classic paper on this subject. Alexis Carrel gave his library to Dr Hufnagle who wrote an excellent treatise on Paget-Schroetter.
Robert Linton, a vascular surgeon, was interested in thrombosis. John Gibbon and his whole laboratory worked on thrombosis, mainly of the pulmonary artery, thrombectomy of the pulmonary artery—that is why they designed the heart-lung machine.
I am indebted to my partners who have all had a great deal to do with these results, particularly Dr Razzuk.
Related Article
Ann. Thorac. Surg. 2000 69: 1663-1668.
This article has been cited by other articles:
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  W. F. Baker Jr Thrombolytic Therapy Clinical and Applied Thrombosis/Hemostasis, October 1, 2002; 8(4): 291 - 314. [PDF]
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