Thrombolytic therapy followed by first rib resection for spontaneous ("effort") subclavian vein thrombosis

Spontaneous (effort) subclavian vein thrombosis in young persons has historically produced long-term disability from arm swelling and exercise limitation because of failure of the occluded vein to recanalize. Several investigators have speculated that the use of thrombolytic therapy to produce clot dissolution followed by resection of the first rib to prevent recurrence might be ideal management of this condition. Our recent experience with treatment of two such patients formed the basis for this report. Two young men were seen within 24 hours of onset of acute arm swelling, found by venography to be caused by acute thrombosis of the subclavian vein at the level of the first rib. They were treated with systemic thrombolytic therapy with intravenous streptokinase. Both had prompt resolution of all signs and symptoms, confirmed by repeat venography to be accompanied by recanalization of the occluded veins. Both were then anticoagulated with heparin followed by warfarin and underwent elective first rib resection, after which anticoagulation was discontinued. Both patients have remained asymptomatic. Persistent venous patency has been confirmed by repeat venography. Thrombolytic therapy to recanalized spontaneous (effort) subclavian vein thrombosis followed by first rib resection appears to be an advance in the treatment of this condition and may avoid the long-term disability with which it has historically been associated.