title: Primary axillary-subclavian venous thrombosis: is aggressive surgical intervention justified?
abstract: Multimodal (thrombolysis, surgical decompression, venous reconstruction, oral anticoagulation) treatment of primary axillary-subclavian venous thrombosis was reviewed to assess the impact of venous patency on functional outcome. Since 1996, 7 patients (6 men, 1 woman) of ages 16-53 years (mean 33 years) presented with symptomatic acute axillosubclavian venous thrombosis as a result of a recent athletic or strenuous arm activity. Five patients had undergone previous (>2 weeks) catheter-directed thrombolysis and venous angioplasty. Diagnostic contrast venography followed by repeat catheter-directed thrombolysis demonstrated abnormal (residual stenosis [n=6] or occlusion [n=1]) axillosubclavian venous segments in all patients. Surgical intervention was performed at a mean interval of 7 days (range 1-19 days) after thrombolysis and consisted of thoracic outlet decompression with scalenectomy and 1st rib resection via a paraclavicular (n=4) or supraclavicular (n=3) approach. Medial claviculectomy or cervical rib resection was performed in 2 patients. Concomitant venous surgery was performed in all patients to restore normal venous patency by circumferential venolysis (n=7) and balloon catheter thrombectomy (n=3), or vein-patch angioplasty (n=2), or endovenectomy (n=5), or internal jugular transposition (n=2). Postoperative venous duplex testing beyond 1 month identified recurrent thrombosis in 4 patients despite therapeutic oral anticoagulation. Subsequent venous recanalization was documented in 3 patients. Poor functional outcome was associated with an occluded venous repair and extensive venous thrombosis on initial presentation. A patent or recanalized venous repair present in 6 of 7 patients was associated with good functional outcome and may justify multimodal intervention in patients with primary axillosubclavian effort thrombosis presenting with recurrent thrombosis and significant residual disease after thrombolysis.
authors.affiliation: Division of Vascular Surgery, University of South Florida College of Medicine, Harbourside Medical Tower #650, 4 Columbia Dr., Tampa, FL 33606, USA.
authors.forename: D C
authors.initials: DC
authors.lastname: Schmacht
authors.forename: M R
authors.initials: MR
authors.lastname: Back
authors.forename: M L
authors.initials: ML
authors.lastname: Novotney
authors.forename: B L
authors.initials: BL
authors.lastname: Johnson
authors.forename: D F
authors.initials: DF
authors.lastname: Bandyk
mesh_terms: D000293:Adolescent; D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D001367:Axillary Vein / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D013350:Subclavian Vein / Q000000981:diagnostic imaging / Q000601:surgery; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency / Q000502:physiology; D014656:Vascular Surgical Procedures; D020246:Venous Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery*; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin