Evolving strategies for the management of venous thoracic outlet syndrome

Traditional management of venous thoracic outlet syndrome (VTOS) has involved catheter-directed thrombolysis (CDT) followed by transaxillary or paraclavicular (PC) first rib resection. More recently, we have adopted an infraclavicular (IC) approach for first rib resection and five other strategies to treat these patients. We report our evolving experience with the treatment of acute VTOS.

We reviewed our prospectively maintained database to identify patients treated for VTOS. Our strategy includes CDT with pharmacomechanical thrombectomy, IC first rib resection during the same hospitalization, and subclavian vein angioplasty immediately after rib resection. Postoperatively, a sequential compression device was applied to the affected arm and low-dose heparin given through the ipsilateral venous sheath. Antiplatelet therapy was given for 6 weeks and anticoagulation for 6 months. Our strategy evolved from a PC to an IC approach, given that the added morbidity of the supraclavicular approach to allow excision of the posterior portion of the rib may add no benefit with VTOS compared with arterial or neurogenic thoracic outlet syndrome.

There were 51 patients who underwent first rib resection for VTOS, 11 (22%) through a PC approach and 40 (78%) through an IC approach. The average age was 36 years (range, 16-63 years), and the majority were female (36 [71%]) and involved the right subclavian vein (36 [71%]). All patients underwent preoperative CDT, 40 (78%) at our hospital and 11 (22%) elsewhere. Fifty patients (98%) underwent subclavian vein angioplasty after rib resection. A bare-metal stent was placed in two (4%) patients for persistent stenosis. Average length of stay was 3.7 (±2.1) days. Average operative time was 2.2 hours (range, 1.5-3.0 hours) when the IC approach was used vs 3.5 hours (range, 2.5-4.5 hours) for the PC approach (P < .0001). Of the entire group, one (2.6%) patient required reoperation for wound hematoma and six (12%) patients underwent repeated endovascular intervention for recurrent vein stenosis during follow-up (average, 38 months; range, 1-240 months). Primary and assisted primary patency rates at 3 years were 78% and 100%, respectively. There were no significant differences in patency rates or complications between the IC and PC approaches.

Our transition to an IC approach demonstrated low perioperative morbidity and excellent subclavian vein patency rates with shorter operative times compared with a PC approach. Our practice has evolved to include IC first rib resection followed by concomitant postoperative venous balloon angioplasty.