title: Concurrent venography during first rib resection and scalenectomy for venous thoracic outlet syndrome is safe and efficient.
abstract: OBJECTIVE
  Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography.
  
  
  METHODS
  Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications.
  
  
  RESULTS
  Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17-52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis.
  
  
  CONCLUSIONS
  FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms.
authors.affiliation: Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass.
authors.forename: Alexander T
authors.initials: AT
authors.lastname: Hawkins
authors.affiliation: Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass.
authors.forename: Maria J
authors.initials: MJ
authors.lastname: Schaumeier
authors.affiliation: Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass.
authors.forename: Ann D
authors.initials: AD
authors.lastname: Smith
authors.affiliation: Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, Mass.
authors.forename: Marit S
authors.initials: MS
authors.lastname: de Vos
authors.affiliation: Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass.
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Ho
authors.affiliation: Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass.
authors.forename: Marcus E
authors.initials: ME
authors.lastname: Semel
authors.affiliation: Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: llnguyen@partners.org.
authors.forename: Louis L
authors.initials: LL
authors.lastname: Nguyen
mesh_terms: D000293:Adolescent; D000328:Adult; D000800:Angioplasty, Balloon; D019299:Decompression, Surgical; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D012189:Retrospective Studies; D012272:Ribs / Q000601:surgery*; D013350:Subclavian Vein / Q000601:surgery; D013901:Thoracic Outlet Syndrome / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult