Abstract
Objective
Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS.
Methods
We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ2 test to compare baseline characteristics and postoperative outcomes.
Results
Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84).
Conclusions
TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency.
Keywords: Venous thoracic outlet syndrome, Balloon angioplasty, Transaxillary first rib resection, Effort thrombosis, Deep vein thrombosis
Article Highlights.
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Type of Research: Single-center retrospective cohort study
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Key Findings: We included 103 patients underwent transaxillary first rib resection for venous thoracic outlet syndrome with a completely occluded axillosubclavian vein. By 14 months, 75% attained venous patency, and 95.2% experienced symptomatic improvement. There were no significant differences in venous patency between different groups of chronicity.
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Take Home Message: Transaxillary first rib resection offers benefits to all patients with symptomatic venous thoracic outlet syndrome and complete occlusion of their axillosubclavian veins, even among patients with chronically occluded veins (>12 weeks).
Thoracic outlet syndrome (TOS) is a clinical diagnosis characterized by a constellation of symptoms caused by compression of the neurovascular structures of the thoracic outlet.1 Venous TOS (VTOS) refers to thrombosis of the axillosubclavian vein as a result of repeated compression of the subclavian vein between the clavicle, first rib, anterior scalene muscle, subclavius muscle, and the costoclavicular ligament.2 VTOS is also frequently referred to as Paget-Schroetter syndrome, or sometimes effort thrombosis, an older term associating VTOS with repetitive muscular exertion.2,3
VTOS is the second most common type of TOS, with approximately 1 in 100,000 diagnosed per year.2,4 VTOS most commonly affects physically active males in their 30s, and patients often present with swelling of the affected arm, associated with cyanosis and pain.5 VTOS is a clinical diagnosis, based on a thorough history and physical examination, with confirmation of the diagnosis supplemented by imaging. Duplex ultrasound examination is the current preferred imaging modality for the diagnosis of VTOS, with a sensitivity of 78% to 100% and specificity of 82% to 100%.4,6 Treatment of VTOS revolves around symptomatic treatment of the associated thrombus with anticoagulation or thrombolysis, followed by definitive treatment of the extrinsic compression on the vein with surgical intervention.2 Without definitive treatment, VTOS is associated with a significant risk of reocclusion.7 Therefore, surgical decompression, which involves surgical resection of the first rib, is often recommended.
Several approaches to first rib resection have been described, including the infraclavicular, supraclavicular, paraclavicular and transaxillary approaches.8, 9, 10 Of these, transaxillary first rib resection (TFRR) offers the advantage of excellent exposure, enabling a high success rate for complete resection of the first rib, fewer collateral vein ligations, while still providing cosmetic appeal. Moreover, TFRR permits treatment of any concomitant symptoms of neurogenic TOS, which can occur in 10% to 20% of individuals suffering from VTOS.11
The favorable long-term outcomes of TFRR in the treatment of VTOS are well-established in the literature.7,12,13 However, there are limited data on the outcomes of TFRR in the treatment of completely occluded axillosubclavian veins in patients with VTOS. Furthermore, little is known about the impact of chronicity on the long-term postoperative outcomes in this group of patients. This study aims to evaluate the short- and mid-term outcomes of TFRR in patients with VTOS and completely occluded axillosubclavian veins based on chronicity.
Methods
We performed a retrospective institutional review of all patients who presented with VTOS between January 1, 2003, and December 31, 2022, at The Johns Hopkins Hospital. Patients who had a completely occluded axillosubclavian vein at the time of TFRR were identified. This cohort included patients who had previously undergone thrombolysis (at a referring or our own institution) but had since subsequently reoccluded before TFRR.
Complete occlusion was defined as the absence of proximal venous blood flow as detected on ultrasound imaging of the axillosubclavian vein. Veins that had a barely patent lumen or just trickle flow at intermittent locations were deemed to be occluded as well. Surgical decompression included TFRR as well as excision of the costoclavicular ligaments/subclavius muscle that was compressing the subclavian vein. Anticoagulation was resumed 4 to 7 days after surgery, and a venogram performed 2 to 3 weeks after surgery. Venography was performed via the ipsilateral basilic vein, or occasionally the brachial vein. Venous patency was determined after contrast injection and attempts were then made to cross any high-grade stenosis or occlusion. These lesions were treated with balloon angioplasty to restore patency. Patients who were treated successfully with balloon angioplasty were then continued on anticoagulation for another 3 months with follow-up duplex imaging performed at that visit and again at 12 months. Patients whose veins could not be crossed and remained occluded were treated with 6 months of anticoagulation, followed with duplex imaging at 12 months. This study was conducted as approved by the Institutional Review Board at Johns Hopkins University School of Medicine. The need for informed consent was waived given the retrospective nature of the study.
Statistical analysis
The patients were categorized into three groups based on acuity of venous occlusion; from the time of inciting VTOS event to TFRR: <4 weeks (n = 28), 4 to 12 weeks (n = 36), and >12 weeks (n = 39). Patient demographics, perioperative characteristics, and postoperative outcomes were recorded. Patients who underwent pre-TFRR thrombolysis were considered successful if there was restoration of venous flow at the occluded site at the end of the thrombolytic treatment. Outcome variables, including venous patency based on duplex findings and subjective symptomatic improvement from swelling and pain at the time of follow-up, were recorded. Venous patency on postoperative ultrasound examination was defined as the presence of blood flow in the axillosubclavian vein at the original occlusion site. We evaluated the association of TFRR timing with 1-year outcomes including venous patency and symptomatic improvement.
Statistical analysis of our database was performed using the Stata MP 14.0 software (StataCorp, College Station, TX). Nonparametric equality-of-median and χ2 tests were used to compare categorical and continuous variables, respectively. Categorical variables are presented in this study as counts and percentages, while continuous variables are presented as medians and interquartile ranges (IQRs). A P value of <.05 was considered statistically significant.
Results
We included 447 patients with symptomatic VTOS underwent TFRR between January 1, 2003, to December 31, 2022. Of these patients, 103 (23.0%) had a completely occluded axillosubclavian vein before TFRR and were included in this study. The patients had a median age of 30.0 years (IQR, 20.0-43.0 years), with 44 female (42.7%), 9 non-White (8.8%) , and the majority nonsmokers (91.3%). TFRR was performed on the dominant extremity in 63 patients (62.4%).
The patients were categorized into three groups based on chronicity of their venous occlusion before TFRR: 28 patients (27.2%) had occlusion for <4 weeks, 36 patients (34.9%) for 4 to 12 weeks, and 39 patients (37.9%) for >12 weeks (Table I). The patients with more chronic occlusion were less likely to have had thrombolysis before TFRR; 24 patients (85.7%) in the <4 weeks group underwent thrombolysis, as compared with 18 (50.0%) and 15 (38.5%) in the 4- to 12-weeks group and >12 weeks group (P < .001). Among patients who underwent pre-TFRR thrombolysis, venous patency was achieved in approximately 66.7% to 80.0% of patients, and there were no significant differences between groups (P = .67) (Table I). Despite thrombolysis being deemed successful at the time of the procedure, these patients had complete re-occlusion of their axillosubclavian veins before TFRR.
Table I.
Preoperative and clinical characteristics among patients with complete occlusion of axillosubclavian veins, categorized by chronicity
| Total (n = 103) | <4 weeks (n = 28) | 4 to 12 weeks (n = 36) | >12 weeks (n = 39) | P value | |
|---|---|---|---|---|---|
| Age, years | 30.0 (20.0-43.0) | 35.0 (19.0-46.0) | 22.5 (19.0-35.0) | 34.0 (27.0-43.0) | .03 |
| Female | 42.7 (44) | 46.4 (13) | 38.9 (14) | 43.6 (17) | .82 |
| Race | .38 | ||||
| White | 91.2 (94) | 92.9 (26) | 86.1 (31) | 94.9 (37) | |
| Black/African American | 3.9 (4) | 3.6 (1) | 5.6 (2) | 2.6 (1) | |
| Asian | 1.0 (1) | 3.6 (1) | 0.0 (0) | 0.0 (0) | |
| Other | 3.9 (4) | 0.0 (0) | 8.3 (3) | 2.6 (1) | |
| VTOS on dominant extremity | 62.4 (63) | 69.2 (18) | 63.9 (23) | 56.4 (22) | .56 |
| Current smoker | 8.7 (9) | 3.6 (1) | 13.9 (5) | 7.7 (3) | .33 |
| Patients who underwent thrombolysis | 55.3 (57) | 85.7 (24) | 50.0 (18) | 38.5 (15) | <.001 |
| Deemed successful | 71.9 (41) | 66.7 (16) | 72.2 (13) | 80.0 (12) | .67 |
| Deemed unsuccessful | 28.1 (16) | 33.3 (8) | 27.8 (5) | 20.0 (3) | |
| Time between thrombolysis and TFRR | 28.0 (11.0-60.0) | 11.0 (7.0-22.0) | 37.0 (24.0-51.0) | 119.0 (67.0-207.0) | <.001 |
TFFR, Transaxillary first rib resection; VTOS, venous thoracic outlet syndrome.
Values are median (interquartile range) or percent (n).
Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 22 patients (78.6%) in the <4 weeks group, 26 (72.2%) in 4- to 12-weeks group, and 24 (61.5%) in >12 weeks group had some degree of recanalization (P = .76) (Table II). Four patients did not undergo postoperative venograms for various reasons. Subsequently, during the initial postoperative follow-up at 4 to 7 months, 71 patients (71.7%) achieved some degree of patency; 23 (85.2%) of which were in the <4 weeks group, 22 (64.7%) in the 4- to 12-weeks group, and 26 (68.4%) were in the >12 weeks group. At 10 to 14 months, the overall patency rate increased to 75.0% (n = 63). An improvement in venous patency was observed in the 4- to 12-weeks (73.3%) and >12 weeks (73.3%) groups. No statistical significance was found in postoperative venous patency between the three groups at both follow-up periods (4-7 months, P = .18; 10-14 months, P = .86).
Table II.
Postoperative outcomes of all patients following transaxillary first rib resection (TFRR), categorized by chronicity
| Total (n = 103) | <4 weeks (n = 28) | 4 to 12 weeks (n = 36) | >12 weeks (n = 39) | P value | |
|---|---|---|---|---|---|
| Patency at postoperative venogram | .76 | ||||
| Widely patent | 10.7 (11) | 10.7 (3) | 8.3 (3) | 12.8 (5) | |
| Stenosed | 59.2 (61) | 67.9 (19) | 63.9 (23) | 48.7 (19) | |
| Occluded | 26.2 (27) | 17.9 (5) | 25.0 (9) | 33.3 (13) | |
| Patent at 4-7 months | 71.7 (71) | 85.2 (23) | 64.7 (22) | 68.4 (26) | .18 |
| Patent at 10-14 months | 75.0 (63) | 79.2 (19) | 73.3 (22) | 73.3 (22) | .86 |
| Improvement in symptoms after TFRR | 95.2 (80) | 95.7 (22) | 96.7 (29) | 93.5 (29) | .84 |
Values are percent (n).
Post-TFRR balloon angioplasty was successfully performed in 60 patients (60.6%) who had a stenosed or occluded axillosubclavian vein at the time of postoperative venogram; 18 (66.7%), 23 (65.7%), and 19 (51.4%) patients in the <4 weeks, 4- to 12-weeks, and >12 weeks groups, respectively (P = .35) (Table III). The overall venous patency rate in this group reached 83.1% at the 4- to 7-month follow-up, and further increased to 87.0% at the 10- to 14-month follow-up. There was no difference in the patency of the axillosubclavian vein based on chronicity; 80.0% of patients (n = 12) in the <4 weeks group, 85.0% (n = 17) in the 4- to 12-weeks group, and 100% (n = 11) in the >12 weeks groups at 10 to 14 months (P = .31).
Table III.
Postoperative outcomes of patients who underwent balloon angioplasty after transaxillary first rib resection (TFRR), categorized by chronicity
| Total (n = 103) | <4 weeks (n = 28) | 4 to 12 weeks (n = 36) | >12 weeks (n = 39) | P value | |
|---|---|---|---|---|---|
| Underwent balloon angioplasty | 60.6 (60) | 66.7 (18) | 65.7 (23) | 51.4 (19) | .35 |
| Patency after balloon angioplasty | |||||
| Patent at 4-7 months | 83.1 (49) | 88.9 (16) | 77.3 (17) | 84.2 (16) | .61 |
| Patent at 10-14 months | 87.0 (40) | 80.0 (12) | 85.0 (17) | 100.0 (11) | .31 |
Values are percent (n).
On postoperative venogram, 27 patients (26.2%) had persistently occluded veins despite attempts at recanalization. However, 10 patients (41.7%) demonstrated recanalization at 10 to 14 months (Table IV). Although not statistically significant, a higher proportion of patients in the <4 weeks group demonstrated patency at both 4 to 7 months (75.0% vs 37.5% in the 4- to 12-weeks group and 33.3% in >12 weeks group; P = .33) and 10 to 14 months (50.0% vs 42.9% in 4- to 12-weeks group and 38.5% in >12 weeks group; P = .92).
Table IV.
Postoperative outcomes of patients who remained occluded at venogram after transaxillary first rib resection (TFRR), categorized by chronicity
| Total (n = 103) | <4 weeks (n = 28) | 4 to 12 weeks (n = 36) | >12 weeks (n = 39) | P value | |
|---|---|---|---|---|---|
| Occluded at postoperative venogram | |||||
| Patent at 4-7 months | 41.7 (10) | 75.0 (3) | 37.5 (3) | 33.3 (4) | .33 |
| Patent at 10-14 months | 41.7 (10) | 50.0 (2) | 42.9 (3) | 38.5 (5) | .92 |
Values are percent (n).
Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84). Overall, 80 patients (95.2%) had symptomatic improvement after TFRR at the 1-year follow-up.
Discussion
In this study, we investigated the outcomes of TFRR in patients with symptomatic VTOS presenting with persistent completely occluded axillosubclavian veins at various time intervals, and our findings shed light on the effectiveness of TFRR across different chronicity. Given that many of our patients were referred from other centers, they arrived at varying stages of treatment, with some solely on anticoagulation and others having previously undergone thrombolysis.
Although thrombolysis offers short-term benefits of symptomatic relief and restoration of flow, it is not the definitive treatment for VTOS, owing to a high rate of rethrombosis.2,7,14 More than one-half of the patients (55.3%) in our cohort had undergone thrombolysis before TFRR. In line with the findings of Dadashzadeh et al,15 our patients in the <4 weeks group had a significantly higher frequency of undergoing thrombolysis (85.7%) than those in the 4- to 12-weeks group (50.0%) and the >12 weeks group (38.5%). Unfortunately, despite deemed to have had a successful thrombolysis procedure, they still presented with complete reocclusion on their axillosubclavian veins. A systematic review including 12 case series of patients with acute effort thrombosis who underwent thrombolysis demonstrated higher rates of symptom resolution and venous patency among patients who underwent first rib resection compared with those who did not undergo first rib resection. In fact, 93% to 95% of patients who underwent a first rib resection had symptom resolution, as compared with 63% in patients who only had thrombolysis. Their review also showed that 40% of patients who were treated conservatively after thrombolysis eventually required a first rib resection.7
One of the key findings of our study is that TFRR consistently demonstrated high rates of venous patency and symptomatic improvement, even among patients with chronically occluded veins. Overall, 75% of patients who initially had completely occluded veins achieved restoration of flow in their axillosubclavian veins by 14 months. There were no significant differences in venous patency between different groups of chronicity, suggesting that TFRR offers benefits to all patients with symptomatic VTOS and complete occlusion of their axillosubclavian veins even among patients with chronically occluded veins (>12 weeks).
Although some patients had persistently occluded axillosubclavian veins, ≤95.2% of patients in this cohort reported significant improvement in swelling, pain, and functionality of the affected upper extremity by 1 year after surgery, again without a significant difference between groups. Whether this result is attributed to the development of venous collateral flows in the setting of chronic occlusion over time or the relief of extrinsic compression across the existing collaterals remains unknown.16 In a case series by Cheng et al,17 the authors reported that 36% of patients had persistently occluded subclavian veins following first rib resection and recanalization attempts. Using standardized functional outcome measures, the authors demonstrated similar findings where symptomatic improvement was observed regardless of venous patency after first rib resection.17
Patients with VTOS commonly present with intrinsic vein defects caused by chronic repetitive injury to the endothelium. This process often leads to post-traumatic inflammation in the veins, resulting in luminal narrowing owing to intimal fibrosis of the vessel.2 Therefore, we perform balloon angioplasty in patients with stenosed or occluded veins on postoperative venogram. Although the concept of postoperative balloon angioplasty after thoracic decompression has been well-established in previous studies,14 our study shows that postoperative balloon angioplasty was able to restore venous patency, even though patients had completely occluded veins at baseline. The need for postoperative balloon angioplasty and its outcome were also similar regardless of chronicity. Notably, overall venous patency rate of those that were able to undergo postoperative balloon angioplasty reached 83.1% at 4 to 7 months, and further increased to 87.0% at 10 to 14 months. We adopted a staged approach at our institution, delaying balloon angioplasty to 2 to 3 weeks after TFRR to allow potential vein recanalization after surgical decompression, thereby increasing the success rate of balloon angioplasty. Our findings support this strategy; approximately 70% of patients experienced some degree of vein recanalization after surgical decompression.
Although our study provides insights into the outcomes of TFRR concerning the chronicity of complete occlusion in VTOS, it is important to acknowledge several limitations. First, the retrospective design and the single-center nature limit the generalizability of our findings to other clinical settings. Second, most of our patients first received treatment at different facilities before being referred to our center for definitive treatment. This factor introduces variability in the duration and type of anticoagulation, as well as in the locations and practices of pre-TFRR thrombolysis, carried out by various interventionists. Additionally, our evaluation of symptom severity and symptomatic resolution relied on subjective patient-reported assessment rather than standardized measures such as quality-of-life questionnaires, formal disability scales, or arm circumference measurements, potentially limiting the objectivity of our findings. Owing to the coronavirus disease 2019 pandemic, there were some scheduling limitations during this period, contributing to some variability in follow-up imaging. Finally, the absence of a control group of occluded VTOS patients who did not receive TFRR limits our ability to draw robust comparative conclusions. Further multicenter, prospective studies are warranted to validate these findings and elucidate optimal treatment strategies.
Conclusions
Our study demonstrates that TFRR offers excellent postoperative outcomes in patients with symptomatic VTOS, in the setting of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion.
Author Contributions
Conception and design: JN, LT, YL
Analysis and interpretation: JN, LT, AM, CH, JW, CH, CA, JF, YL
Data collection: JN, LT, YL
Writing the article: JN, LT, AM, YL
Critical revision of the article: JN, LT, AM, CH, JW, CH, CA, JF, YL
Final approval of the article: JN, LT, AM, CH, JW, CH, CA, JF, YL
Statistical analysis: Not applicable
Obtained funding: Not applicable
Overall responsibility: YL
JN and LT contributed equally to this article and share co-first authorship.
Disclosures
None.
From the Society for Vascular Surgery
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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