130 A B Figure 1 A: Enhanced computed tomography (CT) showing right subclavian vein occlusion (arrow). B: Axial image showing subcutaneous vein conges

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1 Online publication August 10, 症例報告 Paget-Schroetter 1 要旨 :Paget-Schroetter 40 CT Paget-Schroetter L 8 1 follow up J Jpn Coll Angiol 2014; 54: Key words: Paget-Schroetter syndrome, subclavicular approach はじめに 1 2 Paget-Schroetter P-S , 2 costoclavicular space 1 症例 doi: /jca CT 31.5 cm 29 cm 27 cm 26.5 cm CT Fig. 1A B B 血栓吸引溶解療法 6 Fr sheath Fig. 2A P-S 6 Fr Thrombuster III

Figure 2 A: Initial venography image showing total occlusion and floating thrombus.

2 130 A B Figure 1 A: Enhanced computed tomography (CT) showing right subclavian vein occlusion (arrow). B: Axial image showing subcutaneous vein congestion in the right arm (arrow). Figure 2 A: Initial venography image showing total occlusion and floating thrombus. B: Image of the thrombus removed from the right subclavian vein using an aspiration catheter. C: Venography image after thrombectomy and thrombolysis showing no residual thrombus. A B C Fig. 2B FOUNTAIN INFUSION SYSTEM SHEEN MAN Co. Ltd. catheter directed thrombolysis Fig. 2C PT-INR 手術 Molina G Fig. 3A L L side-clamp Fig. 3B Fig. 3C 脈管学 Vol. 54

A B C Figure 4 One year after surgery, duplex scanning image showing neither residual thrombus nor stenosis in the right subclavian vein in 90 degrees of abduction with lateral rotation.

3 131 Online publication August 10, 2014 Figure 3 A: Preoperative venography image showing severe stenosis in the right subclavian vein. B: Image of right subclavian vein after venoplasty with a great saphenous vein patch (arrow). C: Postoperative venography showing good dilatation and blood ﬂow in the right subclavian vein. A B C Figure 4 One year after surgery, duplex scanning image showing neither residual thrombus nor stenosis in the right subclavian vein in 90 degrees of abduction with lateral rotation. 術後 follow-up Duplex scan では残存血栓を認めず良好な血流が確認され右上肢外転位でも良好な血流が確認された Fig. 4 術後は Molina らの管理法に従って 8 週間の抗凝固療法術後 1 年での上肢周径は右上腕 28 cm 右前腕 27 cm 3 日間のヘパリン静注とそれに続くワーファリンの内左上腕 28 cm 左前腕 27 cm で左右差を認めず身体服と三角巾による右上肢固定を行い 1 カ月後 6 カ 3 月後 1 年後に duplex scan による血流評価を行った活動でもとくに制限を認めていない

4 132 考察 P-S 4, Paget Schroetter 1948 Hughes Paget-Schroetter 7 effort thrombosis costoclavicular space 7, 8 P-S DeWeese P-S Urschel 1 10 Molina percutaneous transluminal angioplasty; PTA + PTA / 9 Urschel PTA PTA 13 Molina 3 8 Urschel 14 Kunkel Melby paraclavicular approach patch-plasty 5 2 incision 1 16 Molina L 3, 17 結語利益相反脈管学 Vol. 54

5 133 文献 1 Lindblad B, Tengborn L, Bergqvist D: Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg 1988; 2: Illig KA, Doyle AJ: A comprehensive review of Paget- Schroetter syndrome. J Vasc Surg 2010; 51: Molina JE, Hunter DW, Dietz CA: Paget-Schroetter syndrome treated with thrombolytics and immediate surgery. J Vasc Surg 2007; 45: Cronenwett JL, Johnston KW: Rutherford s Vascular Surgery, 7th Ed, Saunders Elsevier, Philadelphia, 2010, Melby SJ, Vedantham S, Narra VR, et al: Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome). J Vasc Surg 2008; 47: ; discussion Paget J: Clinical lectures and essays. London, Longmans Green, Hughes ESR: Venous obstruction in the upper extremity (Paget-Schroetter s syndrome). A review of 320 cases. Int Abstr Surg 1949; 88: Molina JE: Surgery for effort thrombosis of the subclavian vein. J Thorac Cardiovasc Surg 1992; 103: DeWeese JA, Adams JT, et al: Subclavian venous thrombectomy. Circulation 1970; 41 (5 Suppl): II Urschel HC, Razzuk MA: Paget-Schroetter syndrome: what is the best management? Ann Thorac Surg 2000; 69: ; discussion Urschel HC, Patel AN: Surgery remains the most effective treatment for Paget-Schroetter syndrome: 50 years experience. Ann Thorac Surg 2008; 86: ; discussion Urschel HC, Patel AN: Paget-Schroetter syndrome therapy: failure of intravenous stents. Ann Thorac Surg 2003; 75: ; discussion Lee JT, Karwowski JK, Harris EJ, et al: Long-term thrombotic recurrence after nonoperative management of Paget- Schroetter syndrome. J Vasc Surg 2006; 43: Urschel HC, Kourlis H: Thoracic outlet syndrome: a 50-year experience at Baylor University Medical Center. Proc (Bayl Univ Med Cent) 2007; 20: Kunkel JM, Machleder HI: Treatment of Paget-Schroetter syndrome. A staged, multidisciplinary approach. Arch Surg 1989; 124: ; discussion , Paget-Schroetter ; 19: 7 11 A Case Report of a Primary Subclavian Vein Thrombosis Tatsuya Kaneshiro, Toshimi Yonaha, and Hideyoshi Henzan Department of Vascular Surgery, Nakagami General Hospital, Okinawa, Japan Key words: Paget-Schroetter syndrome, subclavicular approach Young healthy people sometimes suffer from Paget-Schroetter syndrome, which is a relatively rare condition that has been associated with a controversial treatment strategy. This case report presents a male patient in his 40 s, who visited our hospital because of sudden swelling of the right arm. Thrombosis of the right subclavian vein was detected by ultrasound and enhanced computed tomography. Transcatheter thrombectomy and thrombolysis were performed. The patient was diagnosed with Paget-Schroetter syndrome and, subsequently, underwent surgery. Using a subclavicular approach, the first right rib, costoclavicular ligament, and anterior scalene muscles were resected, and intraoperative venography revealed stenosis. Subsequently, the manubrium of the sternum was divided into an L-shape incision and a vein patch was performed. The patient showed an excellent postoperative course that required only 8 weeks of anticoagulation treatment. No recurrence was reported 6 months after surgery. (J Jpn Coll Angiol 2014; 54: ) Online publication August 10, 2014

静脈学 Table 1 Patient characteristics Symptom Case Age Sex Site PE Cause Treatment 1 44 M RSCV swelling (+) unknown UK, anticoaglant patent Result 2 5

静脈学 Table 1 Patient characteristics Symptom Case Age Sex Site PE Cause Treatment 1 44 M RSCV swelling (+) unknown UK, anticoaglant patent Result 2 5 Paget-Schroetter 3 Paget-Schroetter 3 1 1 1 3 86 42 Paget-Schroetter 2013 24 1 71- Paget-Schroetter 3 Table 1 1 44 1 CT 1 2012 4 19 CT CT Fig. 1 2 54 CT Fig. 2 71 静脈学 Table 1 Patient characteristics