Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty.
OBJECTIVE
Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage.


METHODS
Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months.


RESULTS
Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis.


CONCLUSIONS
Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.
Division of Vascular Surgery, University of California, San Francisco 94143-0222, USA. SchneiderD@surgery.ucsf.edu
Darren B
DB
Schneider
Paul J
PJ
Dimuzio
Niels D
ND
Martin
Roy L
RL
Gordon
Mark W
MW
Wilson
Jeanne M
JM
Laberge
Robert K
RK
Kerlan
Charles M
CM
Eichler
Louis M
LM
Messina
D000328:Adult; D017130:Angioplasty / Q000379:methods; D003251:Constriction, Pathologic / Q000209:etiology / Q000628:therapy; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D010690:Phlebography; D011446:Prospective Studies; D013350:Subclavian Vein / Q000000981:diagnostic imaging / Q000601:surgery*; D013901:Thoracic Outlet Syndrome / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods; D016896:Treatment Outcome; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000209:etiology / Q000628:therapy*