Circumferential venolysis and paraclavicular thoracic outlet decompression for “effort thrombosis” of the subclavian vein

Abstract

Effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) has long been considered a primary thrombotic process, but recent experience suggests that it may commonly result from repeated mechanical compression. Increased awareness of the pathophysiology of this syndrome can allow timely, improved diagnostic screening and the use of specific surgical intervention to relieve the venous consequences. During the past 15 years we have treated six patients with mechanical compression in the thoracic outlet causing surgically correctable venous occlusive problems. There were four men and two women with an average age of 38 years (range 26 to 53 years). All patients exhibited pain, swelling, and cyanosis of the upper extremity, with worsening venous congestion on abduction of the arm. Five of six patients were originally treated for effort thrombosis of the subclavian vein with arm elevation and anticoagulation; two also underwent immediate thrombolytic therapy with urokinase. Venography was prompted in each case by positional symptoms during follow-up and showed irregular stenosis of the subclavian vein adjacent to the first rib. All patients underwent extended first rib resection and circumferential venolysis (one patient underwent bilateral procedures); one was performed through a transaxillary approach, two through a supraclavicular approach, and four through a new, "paraclaviculad' approach. All subclavian veins appeared normal after venolysis. Five of six patients also underwent complete scalenectomy and brachial plexus neurolysis. In each patient, venous and neurogenic symptoms resolved and venography confirmed a patent subclavian vein, with follow-up ranging from 11 months to 13 years (mean 3.8 years).

Upper-Extremity Deep Vein Thrombosis

“…Although this disorder may initially cause intermittent, positional extrinsic vein compression, repeated trauma to the vessel can result in dense, perivascular, fibrous scar tissue formation that will compress the vein persistently. 6 Compression of the subclavian vein typically develops in young athletes with hypertrophied muscles who do heavy lifting or completely abduct their arms. Cervical ribs, long transverse processes of the cervical spine, musculofascial bands, and clavicular or first rib anomalies are sometimes found in these patients.…”

“…2 Lysis of dense adhesions around the subclavian vein may also be required if anatomic anomalies have caused chronic, repeated trauma to the vessel. 6 After surgery, venography can assess residual stricture, which should be treated with balloon venoplasty; if this fails, vein stenting can be considered. Long-term patency has been documented with this multimodal approach.…”

A Case of Idiopathic Upper Extremitiy Deep Vein Thrombosis

“…Thompson RW [6] et al was on an opinion that effort on dominant limb can cause thrombosis due to repeated micro trauma to the vein, which might have lead to the thrombosis in our patient. GirolamiA [8] et al studied the frequency of cancers i.e lung in patients presenting with UEDVT, on evaluation of our patient, no cancers were present at presentation and at frequent followups at 1 year.…”

“…2 Lysis of dense adhesions around the subclavian vein may also be required if anatomic anomalies have caused chronic, repeated trauma to the vessel. 6 After surgery, venography can assess residual stricture, which should be treated with balloon venoplasty; if this fails, vein stenting can be considered. Long-term patency has been documented with this multimodal approach [23,27,35,36].…”

“…[8] The prevalence of hypercoagulable states in patients with UEDVT is uncertain because observational studies report varying results. [1][2][3][4][5][6][7][8][9]12] Furthermore, screening for coagulation disorders is controversial and has never been shown to be cost-effective. The yield of these tests is highest for patients presenting with idiopathic UEDVT, a family history of deep vein thrombosis (DVT), a history of recurrent, unexplained pregnancy loss, or a personal history of a prior DVT.…”