Early postoperative hemorrhage after first rib resection for vascular thoracic outlet syndrome

Thrombosis and embolization are the most frequent complications associated with the vascular presentation of thoracic outlet syndrome (VTOS). Therefore, surgery for these conditions requires careful balancing of anticoagulation and hemostasis. Our goal is to identify the optimal postoperative anticoagulation management of these patients.

A prospective database of consecutive patients who have presented to our institution with the diagnosis of thoracic outlet syndrome was reviewed from 1996 through 2010 for instances of postoperative hemorrhage. All venous cases were managed with transaxillary first rib resection followed by postoperative venography and percutaneous angioplasty when required. All arterial cases first underwent thrombolysis, then decompression with transaxillary first and cervical rib resection with concomitant arterial repair when indicated.

Over the study period, 423 patients diagnosed with thoracic outlet syndrome underwent 551 procedures. Of these, 108 presented with VTOS (12 arterial and 96 venous). Mean age of the patients in the cohort was 33.7 ± 11.5 years, with 53 women and 55 men. Postoperative hemorrhage occurred in four patients (4%): three venous cases and one arterial case. Three patients required tube thoracostomy (average blood return: 800 mL) and two required video-assisted thoracoscopic surgery for decortication. Age, gender, preoperative anticoagulation, interval from thrombolysis to surgery, operative duration, and operative blood loss had no effect on the risk of bleeding. No hemorrhage occurred in patients treated with postoperative coumadin alone (82 patients) or with no anticoagulant (24 patients). The four cases of hemorrhage occurred only in patients treated with postoperative low-molecular-weight heparin (LMWH; 14 patients; p < 0.01).

Postoperative hemorrhage was not a common complication of first rib resection for VTOS. In our experience, it occurred exclusively in patients receiving LMWH postoperatively. Postoperative LMWH should be used with caution in patients with VTOS.