Conservative Management of vTOS - VascularWeb

PRIMARY AXILLOSUBCLAVIAN
VENOUS (“EFFORT”) THROMBOSIS
THE CASE FOR AN OBSERVATIONAL APPROACH
Kaj H. Johansen MD, PhD
Swedish Heart and Vascular Institute
*
Seattle, Washington
Vascular Annual Meeting, May 29, 2013, San Francisco, USA

DISCLOSURE
Kaj Johansen MD, PhD, FACS
• I have no financial conflicts of interest
• I’m not anti-surgery: I just want to be sure we’re
doing the right operations for the right patients

AXILLOSUBCLAVIAN VEIN THROMBOSIS (ASVT)
-- most commonly the consequence of indwelling catheters
and wires (secondary ASVT)
-- less commonly, spontaneous axillosubclavian DVT --
“effort” thrombosis or Paget-Schroetter syndrome
(primary ASVT)
-- unusual or untoward upper extremity posture or activity
-- in either circumstance, primary role played by extrinsic
subclavian vein compression in the costoclavicular
space
-- additive contribution by certain prothrombotic states
(Cassada 2006)

PRIMARY ASVT – CLINICAL PRESENTATION
-- young healthy individuals, often physically active
-- relatively acute onset of arm swelling, discoloration, pain
-- concurrent (or subsequent) neurogenic symptoms rare
-- generally symptomatic relatively soon after onset
-- symptoms static or improving: rarely worsen; embolic
symptoms very uncommon
-- duplex ultrasonographic exam shows partial or complete
venous thrombosis; catheter venography confirms

Primary Concern About Primary ASVT…
• Post-thrombotic syndrome (PTS) !!!
-- chronic recurrent upper extremity venous
occlusion or stenosis
-- pain, swelling, discoloration, fatigue

PRIMARY ASVT – INITIAL THERAPY
-- heparin (or enoxaparin, etc.), then warfarin for a minimum
of three months
-- catheter-directed thrombolysis
-- balloon angioplasty of subclavian venous strictures
-- stenting of refractory subclavian venous strictures
-- thoracic outlet decompression
first rib resection
claviculectomy
-- venous reconstruction
venous thrombectomy, patch angioplasty, bypass…

DEBATE
-- operative reconstruction for ASVT is so well
established as the standard of practice that
currently the only real debate revolves around
whether to wait to decompress the subclavian
vein or to proceed ahead during the index
hospitalization
Grassi et al, J Vasc Surg 1999
Capparelli & Freischlag, J Vasc Surg 2005

NATURAL HISTORY OF ASVT -- I
• Upper extremity DVT is morbid and, if untreated,
results inevitably in a chronically swollen, painful
arm (chronic post-thrombotic syndrome, PTS)

OPERATIVE REPAIR FOR ASVT
Thompson et al, J. Vasc. Surg. 1992
Machleder, J. Vasc. Surg. 1993
Rutherford & Hurlbert, Cardiovasc. Surg. 1996
Lee et al, J. Vasc. Surg. 1998
Angle et al, Ann. Vasc. Surg. 2001
Capparelli & Freischlag, Semin. Vasc. Surg. 2005
Melby et al, J. Vasc. Surg. 2008
Overall conclusion from these surgical series:
80-95% longterm venous patency
80-95% relief of symptoms and return
to work and usual activities

SUPPORTIVE LITERATURE
SIGNIFICANTLY SYMPTOMATIC
Swinton et al, Circulation 1968 91%
Tilney et al, Arch. Surg. 1970 74%
Donayre et al, Am. J. Surg. 1986 47%
Gloviczki et al, J. Vasc. Surg. 1986 40%
However…
-- these studies are >25 years old
-- thrombolysis used inconsistently or not at all
-- primary and secondary ASVT
-- level of evidence Grade B - or C at best

NATURAL HISTORY OF PRIMARY ASVT – II
-- beginning in the 1990s, epidemiologic studies of primary
ASVT patients treated just with anticoagulation, or with
anticoagulation and thrombolysis, suggested that many
such patients subsequently did well and did not develop
recurrent DVT or post-thrombotic symptoms
-- such patients often had few or no symptoms even if the
axillosubclavian vein was partially or even
completely occluded (Machleder 1993, Matsumara 1997,
Cassada 2006)

CONTEMPORARY LITERATURE
SIGNIFICANTLY SYMPTOMATIC
Heron et al, Ann. Intern. Med. 1999 13%
Sabeti et al, Thromb. Res. 2002 10%
Martinelli et al, Circulation 2004 10%
Elman & Kahn, Thromb. Res. 2006 15%*
Thomas & Zierler, Vasc. Endovasc. Surg. 2006 12%*
Sajid et al, Acta Haematol. 2007 17%*
Lechner et al, J. Thromb. Haemost. 2008 4%
These studies are…
-- recent (within the past 15 years)
-- internal medicine, epidemiology, vascular medicine
-- primary ASVT only
-- universally, anticoagulation and thrombolysis
-- level of evidence robust Grade B or, in some cases Grade A*

CONTEMPORARY Literature (cont.)
More recent surgical series have resulted in similar
observations…
SIGNIFICANTLY SYMPTOMATIC
Hingorani et al, J. Vasc. Surg. 1997 6%
Lee et al, J. Vasc. Surg. 2000 13%
Lokanathan et al, J. Vasc. Surg. 2001 10%

A personal series…
• 85 consecutive primary ASVT patients treated with
thrombolysis, balloon angioplasty, 3 months of
anticoagulation and vigorous upper extremity exercise
• All offered first rib resection and venous reconstruction
if symptomatic at 12 months
• Follow-up 3–168 months (mean 52 months)
• Results:
-- mild upper extremity swelling at rest or after
exercise in 8.5% of patients (91.5% asymptomatic)
-- NO (n = 0) operations for ASVT since 1995

A TELLING COMPARISON
Among a series of patients undergoing operation for
neurogenic or venous TOS and evaluated pre- and postoperatively
using DASH (AAOS, 1996)…
pre-op post-op p-value
neurogenic TOS 54.0 17.8 0.01
venous TOS 14.9 14.8 NS
Cordobes-Gual et al, Eur. J. Vasc. Endovasc. Surg. 2008

BENIGN NATURAL HISTORY (cont.)
-- The vast majority of patients with secondary
ASVT (due to portacaths, dialysis catheters,
guidewires) are asymptomatic (or only minimally
symptomatic) during longterm followup
Kahn 2006; personal communication 2013

EFFECT OF AXILLARY VEIN EXCISION
• Among 82 patients (102 limbs) undergoing axillary vein
excision for transposition to treat lower extremity chronic
venous insufficiency, 100 upper extremities (98.1%) were
asymptomatic at 38 months mean follow-up…
Raju et al, J Vasc Surg 1999

WHAT’S THE EXPLANATION
-- earlier investigators were probably right: untreated
primary ASVT likely is a morbid condition with a high
likelihood of chronic and recurrent PTS symptoms
-- however, virtually no contemporary ASVT patients go
untreated: all are anticoagulated and the vast majority
undergo an attempt at venous thrombolysis
-- from a hemodynamic perspective, chronic upper
extremity post-thrombotic symptomatology should be
unusual: arm blood volume is minimal, gravity is mostly
irrelevant, the venous occlusion is short, collateral
reserve is robust and most subjects are sedentary

WHERE ARE ALL THE CHRONICALLY
SWOLLEN ARMS
• Seattle, Palo Alto and Vancouver should be awash in
patients with swollen, painful, discolored upper extremities
because they didn’t undergo early thoracic outlet
decompression to treat their upper extremity DVT
• But they are not!
The only chronic upper extremity PTS we see is in:
-- ESRD patients with functioning AV fistulas/grafts and central venous
occlusions/stenoses
-- prior cancer patients with secondary ASVT and XRT
-- failed rib resections/venous reconstructions for primary ASVT

SUMMARY AND CONCLUSIONS
• Operative therapy for primary ASVT is safe, effective and relatively
durable – almost as much so as non-operative therapy!
• This analysis suggests, at the very least, the non-inferiority of
observational care for ASVT
• No credible data clearly demonstrate that operative intervention
predictably improves outcomes in primary ASVT patients
• The current trend to proceed with operative intervention at the time
of the initial hospitalization eliminates the very real possibility that, if
left alone for a time, few of these patients would have required
an operation at all!
“It’s hard to make an asymptomatic patient feel better…” Stanley Hoerr (1952)