Preoperative Thrombolysis and Venoplasty Affords No Benefit in Patency Following First Rib Resection and Scalenectomy for Subclavian Vein Thrombosis

Background: Subclavian vein thrombosis is a rare presentation of thoracic outlet syndrome (TOS). Typical treatment patterns consist of preoperative anticoagulation followed by operative decompression via first rib resection and scalenectomy (FRRS). Recently, thrombolytic therapy has been utilized as initial treatment with anticoagulation and FRRS. The purpose of our study was to review our extensive experience and compare the effectiveness of preoperative thrombolysis and venoplasty to anticoagulation alone in those undergoing FRRS to preserve subclavian vein patency.
Methods: A retrospective review was conducted for all venous TOS patients from July 2003 to May 2009 from a prospectively maintained database. Patient demographics and use of preoperative anticoagulation, thrombolysis, and percutaneous venoplasty was recorded. Following FRRS, reports of follow-up venograms were analyzed with regard to axillosubclavian vein patency, percutaneous venoplasty, results of intervention, and presence of occlusions. Postoperative clinic evaluations and duplex imaging reports were reviewed for presence of symptoms, recanalization, chronic non-occlusive thrombus, or continued complete occlusion.
Results: One hundred three patients had 110 FRRS for subclavian vein thrombosis (53 men, 50 women) seven of which had contralateral FRRS for thrombosis. The cohort averaged 31 years of age (range 16-54) with a mean follow-up time of thirteen months (range 1-52 months). Overall, 65 (59%) were managed with anticoagulation alone prior to FRRS, while 45 patients (41%) had preoperative endovascular interventions prior to FRRS. Of these 45 patients, 22 (49%) underwent thombolysis alone and 23 (51%) underwent thrombolysis and axillosubclavian balloon venoplasty. Following FRRS, 43 (96%) patients had follow-up venograms two weeks post-operatively revealing patent subclavian veins in 15 patients, stenosis requiring balloon dilatation in 21 patients, and 7 occlusions (16%). The overall initial patency rate in this group was 84%. In follow-up, 5 of the 7 occlusions were documented to be recanalized with restoration of the patency of the subclavian vein at a mean of 2.8 months post-operatively (range 1-6 months). In the 65 patients managed with anticoagulation alone prior to FRRS, 61 (94%) underwent follow-up venograms. The venograms revealed patent subclavian veins in 15 patients, stenosis requiring balloon dilatation in 36, and 10 (16%) occlusions. Eight of ten occlusions were documented to be recanalized at an average of 4.3 months (range 1-11 months) following FRRS.
Conclusions: Although initial treatment strategies for subclavian vein thrombosis may differ, a combination of anticoagulation, thrombolysis, operative decompression with FRRS, and post-operative endovascular interventions can yield excellent outcomes. A large proportion of patients in this series (41%) underwent thrombolysis prior to operative decompression with FRRS, but showed no improvement in outcome as determined by vein patency on postoperative venography and duplex imaging during follow-up. Our large series suggests pre-operative treatment with anticoagulation alone has vein patency rates similar to patients undergoing thrombolytic therapy. This treatment paradigm has tremendous cost containment potential as well, given the use of outpatient anticoagulation at initial presentation has an obvious lower cost than inpatient endovascular intervention. Overall, 96% (106/110) of our patients have patent subclavian veins during our follow-up interval, are asymptomatic, and back to their previous active lifestyle.