Multiple treatment algorithms for successful outcomes in venous thoracic outlet syndrome

• Published in: Surgery Vol. 145; no. 5; pp. 500 - 507
• Main Authors: de León, Ricardo A., MD, Chang, David C., PhD, MPH, MBA, Hassoun, Heitham T., MD, Black, James H., MD, Roseborough, Glen S., MD, Perler, Bruce A., MD, Rotellini-Coltvet, Lisa, MA, MMS, PA-C, Call, Diana, BS, RVT, Busse, Christopher, BS, RVT, RDMS, Freischlag, Julie A., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01.05.2009; Elsevier
• Subjects: Adolescent; Adult; Algorithms; Angioplasty; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Female; Fibrinolytic Agents - therapeutic use; Follow-Up Studies; General aspects; Humans; Male; Medical sciences; Middle Aged; Muscle, Skeletal - surgery; Prospective Studies; Ribs - surgery; Surgery; Thoracic Outlet Syndrome - therapy; Tissue Plasminogen Activator - therapeutic use; Treatment Outcome; Young Adult; Multiple; Prognosis; Intravenous administration; Cardiovascular disease; Costoclavicular syndrome; Algorithm; Decision tree; Arterial disease; Vascular disease; Medicine; Treatment; Blood vessel; Surgery; Thoracic outlet syndrome; Evolution; Upper limb; Circulatory system; Vein
• ISSN: 0039-6060; 1532-7361
• DOI: 10.1016/j.surg.2008.09.017

Background We sought to determine the outcomes in patients presenting with venous thoracic outlet syndrome. Methods Prospectively collected data from 67 patients between October 2003 and December 2007. The average age was 31 years (range, 16–54); the 37 males and 30 females presented on average 9.2 months (range, 1 month–6 years) after acute thrombosis. Four treatment algorithms were utilized. Results In group 1, 3 patients presented with acute occlusion and received tissue plasminogen activator (tPA) and immediate first rib resection with scalenectomy (FRRS). One vein rethrombosed and was treated by intravenous tPA postoperatively. In group 2, 39 patients presented with stenotic subclavian veins an average of 22 weeks after their initial thrombosis, all of whom underwent FRRS followed by a venogram 2 weeks postoperatively: 25 had a tight stenosis and underwent venoplasty with anticoagulation; 13 had patent, nonstenotic subclavian veins, and 1 patient required tPA and venoplasty owing to rethrombosis. Two patients had their subclavian vein thrombose after venoplasty and were treated with anticoagulation, tPA, and venoplasty. In group 3, 11 patients presented with intermittent venous obstruction without thrombosis and underwent FRRS; 3 underwent venograms because of concerns of residual stenosis, 2 of whom required venoplasty postoperatively. Finally, in group 4, 14 patients presented with occluded subclavian veins and underwent FRRS with long-term anticoagulation. Eleven have recanalized at an average of 6 months (range, 2–12). Conclusion Overall, 64 of 67 patients have patent subclavian veins after a median follow-up of 10 months, and all patients are asymptomatic for a success rate of 96%. Tailored treatment algorithms including FRRS, postoperative venograms with or without intervention, and the use of long-term anticoagulation seems to be required in this complicated group of young patients to achieve optimal results.