A 40 year old right-handed painter develops a swollen, throbbing right arm after painting a house. The best therapy which would minimize long-term morbidity is

A. first rib resection.
B. intravenous heparin followed by warfarin.
C. immediate thrombectomy followed by urokinase administration and then first rib resection.
D. urokinase therapy alone. 
E. urokinase therapy followed by first rib resection.

Answer E

Effort thrombosis of the axillary or subclavian vein (Pagett-Schroetter syndrome) is due to unusual or excessive use of the arm in addition to the presence of compressive elements in the thoracic outlet. Recognition that there is usually anatomical compression of the subclavian vein by the clavicle, costoclavicular ligament, rib or from the scalene muscle is important. In addition, long-term results with anticoagulation (heparin followed by warfarin) alone have been suboptimal, with residual arm symptoms of swelling, pain and superficial thrombophlebitis in 60-68% of patients. The majority (60%) of patients treated with this conservative approach will require first rib resection for persistent symptoms. Two recent reports demonstrate the superiority of lytic therapy followed by decompression of the thoracic outlet. Good results were reported in 89% and 100% of the patients.