Paget-Schroetter disease medical therapy

An effective treatment approach with lower rate of recurrent thrombus is a combination of anti-coagulation, thrombolytic agents and surgical decompression of the thoracic outlet. Catheter-directed thrombolysis injection has proven to be effective as systemic thrombolytic agents without any worrisome systemic side effects.

• Considering more belligerent treatment methods cite greater outcomes with a lower rate of recurrent thrombus.
• Belligerent treatment method compromises the following:^[1]
  • Anticoagulation
  • Thrombolytic agents
  • Surgical decompression of the thoracic outlet with the repair of the affected venous system
• Monotherapy with anticoagulants is reported inefficient, since approximately 80% of cases ended up with residual venous obstruction and 90% experienced persistence symptoms.^[2]
• Some researchers recommend anticoagulation therapy for at least two to three months, while some other authors deny any benefit from anticoagulation therapy when surgical outcomes are satisfactory.
• Systemic fibrinolysis:
  • More efficient than anticoagulation therapy^[3]
  • Higher chance of developing worrisome complications like intracranial hemorrhage compared to anticoagulation therapy^[4]
• Local catheter-directed thrombolysis:
  • Recommended in all early presenting patients based on some studies^[5], while others suggest this method for sever cases, large thrombus, low risk of bleeding, patients with good general health condition and life expectancy more than a year.^[6]
  • Studies have been demonstrated that there is an indirect relationship between efficacy of local thrombolytic therapy and duration between symptom onset to treatment. Therefore it is critical to diagnose and treat as soon as possible.^[7]
  • Some studies suggest to consider local catheter-directed thrombolysis within the first 14 days of symptoms onset with success rate of 84%.^[8]
  • In a study done by Baylor, none of the cases who underwent catheter-directed thrombolysis more than 6 weeks after symptom onset had a complete vein recanalization.
  • Moreover only 50% of these cases result in partial vein patency.^[9]
  • Based on two studies, success rates of catheter-directed thrombolysis have been reported only 22% and 25% in a large thrombus with greater clot burden.^[10]
  • Same efficacy as systemic thrombolytic agents without any systemic side effects.^[11]
  • Newer agents like Alteplase and Reteplase are safer compared to urokinase or streptokinase.^[12]
  • The average duration of thrombolytic infusion via catheter is estimated between 24-48 hours.^[13]
  • Lee et al. suggested that patients younger than 28 who received thrombolysis had a higher chance of recurrent thrombus. Although more studies is required.^[14]

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