Management of Venous Thoracic Outlet Syndrome - Methodist ...

Heitham T. Hassoun, MD
AUGUST 20 – 22, 2010
Hotel ZaZa, Houston, Texas
Management of Venous Thoracic Outlet
Syndrome (TOS)

Venous TOS – “Effort Thrombosis”
Pathophysiology
• Mechanical abnormality at the costoclavicular portion of
the axillosubclavian vein
• Most often acute thrombosis is in an area of chronic
compression and stricture - between the scalene or
subclavius tendon and the first rib

Multiple treatment algorithms for successful
outcomes in venous thoracic outlet syndrome
Ricardo A. de Leon, MD, David C. Chang, PhD, MPH, MBA, Heitham T. Hassoun, MD, James H. Black, MD,
Glen S. Roseborough, MD, Bruce A. Perler, MD, Lisa Rotini-Coltvet, MA, MMS, PAC, Diana Call, BS, RVT,
Christopher Busse, BS, RVT, RDMS, and Julie A. Freischlag, MD
Background. We sought to determine the outcomes in patients presenting with venous thuracic outlet syndrome. Methods.
Prospectively collected data from 67 patients between October 2003 and December 2007. The average age was
31 years (range, 16-54); the 371lUlleS and 30females presented on average 9.2 months (range, 1 month to 6 years) after acute
thrombosis. Four treatment algorithms were utilized. Results. In group 1, 3 patients presented with acute
occlusion and received tissue plasminogen activatur (tPA) and immediate first rib resection with scalenectomy (FRRS). One
vein rethrombosed and was treated fly intravenous tPA postoperatively. In group 2, 39 patients presented with
stenotic subclavian veins an average of 22 weeks after their initial thrombosis, all of whom underwent FRRS followed by a
venogram 2 weeks postoperatively: 25 had a tight stenosis and underwent venoplasty with anticoagulation; 13 had patent,
nonstenotic subclavian veins, and 1 patient required tPA and venoplasty owing to rethrombosis. Two patients had their subclavian
vein thrombose after venoplasty and were treated with anticoagulation, tPA, and venoplasty. In group 3, 11 patients
presented with intermittent venous obstruction without thrombosis and underwent FRRS; 3 underwent
venograms because of concerns of residual stenosis, 2 of whom required venoplasty postoperatively. Finally, in group 4, 14
patients presented with occluded subclavian veins and underwent FRRS with long-term anticoagulation. Eleven
have recanalized at an average of 6 months (range, 2-12). Conclusion. Overall, 64 of 67 patients have patent
subclavian veins after a median follow-up of 10 months, and all patients are asymptomatic for a
success rate of 96 %. Tailored treatment algorithms including FRRS, postoperative venograms with or without intervention, and the
use of long-term anticoagulation seems to be required in this complicated group of young patients to achieve optimal results.
(Surgery 2009)
From the Department of Surgery, Division of Vascular Surgery, Johns Hopkins Medical Institutions, Baltimore, MD

Treatment # 1: Acute Vein Occlusion
• Three patients (4.5%) presented with acute occlusion of
the subclavian vein (2,3 and 7 days)
• All were lysed, underwent first rib resection and
scalenectomy followed by 2 week postoperative
venogram +/- intervention
• One re-thrombosed and was lysed
• Postoperative anticoagulation was given to all patients
de Leon et al, Surgery 2009

Paget-Schroetter Syndrome
“Effort Thrombosis”

Primary Trombolysis

Post-Thrombolysis

Post-Thrombolysis PTA

Transaxillary 1 st Rib Resection

Treatment # 2: Subclavian Vein Stenosis
• Comprised of 39 (58%) patients who presented
with symptomatic subclavian vein stenosis
• Presented on average 27 weeks following acute
event
• All underwent first rib resection and scalenectomy
followed by 2 week postoperative venogram
de Leon et al, Surgery 2009

Treatment # 2: Subclavian Vein Stenosis
• Postoperative venograms
– 25/39 (64%) had significant stenosis and
underwent PTA
– 13 (33%) were non-stenotic and required no
further intervention
– 1 presented with an occluded subclavian vein
and was treated with lysis then PTA
• Overall, 26 (67%) patients underwent PTA and
were maintained on anticoagulation for 3 months
– 2 (5%) pts required re-intervention at 1 and 5 weeks
de Leon et al, Surgery 2009

Ultrasound-Guided Access

Subclavian Vein Stenosis
“Focal”
• Usually cross with .035 hydrophilic wire and glidecath
• Sometimes need lower profile catheter (ie. QuickCross)

Post-operative Subclavian Vein PTA

Post-operative Subclavian Vein PTA

Post-operative Subclavian Vein PTA

Treatment # 3: Intermittent Vein Obstruction
“McCleery Syndrome”
• 11/67 (16%) patients presented on average 57 weeks
after onset of symptoms
• All presented with swelling but no thrombosis
• All demonstrated vein occlusion with abduction
• All underwent first rib resection and scalenectomy
• Post-operative venograms in 3 patients for persistent
symptoms
- 2 required PTA
• All are currently asymptomatic
de Leon et al, Surgery 2009

Imaging of Intermittent Vein Obstruction

Treatment # 4: Chronically Occluded Veins
• 14/67 (21%) patients presented on average 54 weeks
since their initial thrombosis
• All underwent first rib resection and scalenectomy
followed by venograms in 12 patients
• 6-month course of coumadin
• Duplex scan was utilized in the follow-up period to
assess subclavian vein patency
de Leon et al, Surgery 2009

Complications/Outcomes
• No vascular injury
• No brachial plexus or long thoracic nerve
injury
• 10/67 (15%) pneumothorax
• 64/67 (96%) patients have patent subclavian
veins and are asymptomatic

Failure of stents as primary therapy
Initial experience with venous stents in exertional
axillary-subclavian vein thrombosis
Presented at the Tenth Annual Meeting of the Eastern Vascular Society, Washington, D.C., May 3-5, 1996.
George H. Meier MD, Jeffrey S. Pollak MD, Melvin Rosenblatt MD, Kevin W. Dickey MD and Richard J. Gusberg MD
New Haven, Conn.
JVS 1996

Failure of stents as primary therapy
Complication of a venous wallstent
Richard Dowling,1 Peter Mitchell,1 Geoffrey S Cox2 and Ken R Thomson1
1Department of Radiology and 2Vascular Surgical Unit, Royal Melbourne Hospital, Parkville, Victoria,
Australia
Australasian Radiology (1999) 43, 246–248

Top 3 Future Directions
• Anticoagulation protocol
• IVUS?
• Secondary use of stents?