title: Limited venoplasty and anticoagulation affords excellent results after first rib resection and scalenectomy for subacute Paget-Schroetter syndrome.
abstract: OBJECTIVE
  We have previously demonstrated excellent mid-term patency rates following routine venography after first rib resection and scalenectomy (FRRS) for subacute Paget-Schroetter syndrome. The goal of this study was to assess the long-term outcomes of this technique.
  
  
  METHODS
  Retrospective analysis of a prospectively collected database was performed. Patients underwent routine venography 2 weeks post-FRRS. Warfarin was discontinued in those with patent veins. Patients with stenotic or occluded veins underwent attempted venoplasty with balloon diameters approximating the size of the anatomically normal vein. Patients with successful venoplasty or chronically occluded veins unable to be dilated were continued on warfarin up to 6 months. Follow-up duplex ultrasound dictated cessation of anticoagulation. Kaplan-Meier analysis was performed for primary, primary-assisted, and secondary patency.
  
  
  RESULTS
  A total of 159 patients underwent FRRS and postoperative venography with a median follow-up of 13.8 months. One patient was lost to follow-up. The median time to FRRS after the initial onset of symptoms was 4.1 months. At the time of venography, there were 42 patent, 72 stenotic, and 44 occluded veins. Of the 44 occlusions, 25 underwent venoplasty, and 19 could not be crossed. In the entire group, restenosis occurred in seven patients and reocclusion in seven. At last follow-up, six patients remained occluded. Eighteen-month primary patency of venoplasty was 95.4% ± 2.6% in the stenotic group and 75.6% ± 8.7% in the occluded group. Eighteen-month primary-assisted patency of venoplasty was 98.3% ± 1.7% in the stenotic group and 96.0% ± 3.9% in the occluded group. Overall secondary patency at 3 years was 100% in the patent group, 98.4% ± 1.6% in the stenotic group, and 92.9% ± 3.9% in the occluded group.
  
  
  CONCLUSIONS
  Long-term venous patency rates after limited venoplasty and anticoagulation following FRRS are excellent. Furthermore, prolonged anticoagulation for occlusions that could not be crossed or in those who reocclude after venoplasty results in recanalization and delayed patency. These results argue against the need for stenting or open venous reconstruction and serve as a benchmark for the care of patients with subacute Paget-Schroetter syndrome.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md. Electronic address: cabular1@jhmi.edu.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Danielle H
authors.initials: DH
authors.lastname: Rochlin
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Shalini
authors.initials: S
authors.lastname: Selvarajah
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Ying Wei
authors.initials: YW
authors.lastname: Lum
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag