Abstract
Objective
Venous thoracic outlet syndrome (vTOS) is caused by compression of the subclavian vein at the costoclavicular space, which may lead to vein thrombosis. Current treatment includes thoracic outlet decompression with or without venolysis. However, given its relatively low prevalence, the existing literature is limited. Here, we report our single-institution experience in the treatment of vTOS.
Methods
We performed a retrospective review of all patients who underwent rib resection for vTOS at our institution from 2007 to 2022. Demographic, procedural details, and perioperative and long-term outcomes were reviewed.
Results
A total of 76 patients were identified. The mean age was 36 years. Swelling was the most common symptom (93%), followed by pain (6.6%). Ninety percent of patients had associated deep vein thrombosis, with 99% of these patients starting anticoagulation preoperatively. A total of 91% of patients underwent rib resection via the infraclavicular approach, 2% via the paraclavicular approach (due to a neurogenic component), and 7% via the transaxillary approach. Eighty-three percent of patients had endovascular intervention before or at the time of the rib resection, with catheter-directed thrombolysis (87%), followed by angioplasty (71%) and rheolytic thrombectomy (57%) being the most common interventions. The median time from endovascular intervention to rib resection was 14 days, with 25% at the same admission. The median postoperative stay was 3 days (2-5 days). There was no perioperative mortality or nerve injury. Fourteen percent of patients had postoperative complications, with bleeding complications (12%) being the most common. Waiting more than 30 days between initial endovascular intervention and rib resection was not associated with decreased risk of bleeding complications. Patients were seen postoperatively at 1-month (physical examination) and 6-month (duplex) intervals or for any new or recurrent symptoms. Twenty-two percent of our overall patient population underwent reintervention, most commonly angioplasty (21%). At last follow-up, 97% of subclavian veins were patent, and 93% of patients were symptom free.
Conclusions
Over the last decade, we have transitioned to an infraclavicular approach for isolated vTOS, with low perioperative morbidity and good patency rates. These results support the adoption of the infraclavicular approach with adjunct endovascular techniques as a safe and efficacious treatment of vTOS.
Keywords: Venous thoracic outlet syndrome, Paget-Schroetter, Surgical decompression, Infraclavicular approach, Thrombosis, Thrombolysis
Article Highlights.
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Type of Research: Single-center, retrospective cohort study
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Key Findings: After infraclavicular rib resection at last follow-up, 97% of subclavian veins were patent, and 93% of patients were symptom free, with no perioperative mortality or nerve injury.
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Take Home Message: The findings support the implementation of infraclavicular rib resection in conjunction with endovascular techniques as a safe and effective treatment for venous thoracic outlet syndrome.
Venous thoracic outlet syndrome (vTOS), characterized by the compression of the subclavian vein at the costoclavicular space, is a relatively uncommon condition, with an annual incidence of 1/100,000 people.1,2 However, given its predisposition to affect young, otherwise healthy patients and its associated morbidity of axillo-subclavian deep vein thrombosis (DVT), vTOS poses a significant burden on the health care system.3 Historically, management centered on the use of lifelong anticoagulation but was severely limited due to poor symptom resolution and high rates of recurrent thrombus.4 To address these shortcomings, alternative management strategies aimed at restoring vein patency followed by decompression started to be implemented.5 Current management involves the use of thrombolysis, followed by thoracic outlet decompression with or without venolysis, or additional endovascular interventions to address residual vein stenosis.6, 7, 8
Thoracic outlet decompression is a vital component for the management of vTOS, and its implementation has been long associated with a decrease in recurrent thrombosis and increased symptom resolution.9,10 Decompression is conventionally achieved through first rib resection with scalenectomy. Historically, this was accomplished via a transaxillary (TA) or supraclavicular (SC) approach. However, the infraclavicular (IC) approach has gained popularity because of its ability to provide easier access to the subclavian vein within the costoclavicular space, aiding venolysis.11,12 Although few studies have attempted to compare the outcomes of these different approaches, the scarcity of vTOS cases has contributed to a paucity of comprehensive literature, underscoring the need for institution-specific experiences to illuminate effective strategies.13, 14, 15 We therefore aimed to conduct a retrospective analysis of our institution’s dedicated efforts in managing vTOS and transition to the IC approach, in order to continue to shed light on its safety and efficacy.
Methods
Study design, data source, and patient population
We performed a retrospective analysis of our prospectively collected thoracic outlet decompression database. All patients who underwent rib resection for vTOS at Beth Israel Deaconess Medical Center from February of 2007 to June of 2023 were selected. Patients who were diagnosed with vTOS and initially treated medically or endovascularly at an outside institution but underwent thoracic outlet decompression and subsequent follow-up in our institution were also included. This study was designed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.16 The institutional review board at Beth Israel Deaconess Medical Center approved this study, and informed consent was waived, given the deidentified nature of this study.
Variables
Preoperative and demographic data collected included age, gender, smoking status, relevant comorbidities, hypercoagulability, presenting symptoms, diagnostic imaging, and preoperative anticoagulation use. Prior endovascular management (lysis or angioplasty) at an outside institution was also included. Symptom duration was defined as time between the onset of symptoms and intervention at our hospital or at an outside institution. Perioperative data including endovascular and thoracic outlet decompression operative details and outcomes were recorded. Bleeding complications included transfusion requirement, hemothorax, and hematomas. Only pneumothoraxes requiring intervention (including supplemental O2) were classified as complications. Follow-up data were used to assess symptom resolution, reintervention, and vein patency rates. Routine planned venogram after rib resection was not considered a reintervention unless additional angioplasty or stenting was performed.
Preoperative management
Our protocol for the management of acute vTOS with associated thrombosis, that is, Paget-Schroetter syndrome, involves the insertion of an overnight lysis catheter, followed by pharmacomechanical thrombectomy on the second day—depending on the presence of residual thrombus. Angioplasty is also typically performed on this second day to address residual vein compression. Assuming successful thrombolysis and reestablished patency of the subclavian vein, patients are either discharged home on anticoagulation with scheduled interval first rib resection or undergo surgical decompression during the index hospitalization. This is largely based on patient preference and surgeon availability.
Operative details
In our early (2007-2008) experience, first rib resection was typically performed via a TA approach. However, since 2008, we have almost unanimously adopted the IC approach, given its excellent visualization of the subclavian vein within the costoclavicular space and beyond more medially, thus allowing for more extensive venolysis and its reported decreased morbidity.11,14,15,17
For the IC approach, patients were positioned supine with the ipsilateral arm abducted. An IC incision was made approximately one fingerbreadth below the clavicle, extending from the edge of the sternum. Electrocautery was used to dissect down to the pectoral fascia. The pectoralis major was split between its sternal and clavicular heads, and dissection was carried down to the chest wall identifying the first rib. The subclavius was then retracted superiorly and inferiorly, and the subclavian vein was identified. Dissection was continued at the level of the rib, first at the inferior border and then superiorly. The subclavius was then divided from its insertion onto the superior aspect of the rib and debulked off the clavicle. Dissection was then continued on the inferior border of the rib, dividing the intercostal muscles and pushing the pleura down. The superior border was then cleared off the anterior scalene and its posterior surface from the pleura. The first rib was then divided anteriorly and posteriorly. After rib resection, and adequate exposure of the vein, we performed a venolysis, clearing all of the sclerotic tissue around the vein as medially as possible. A drain was left in the rib resection bed, and the wound was closed. For the paraclavicular (PC) approach, an SC incision starting over the edge of the sternocleidomastoid is made and carried down through subcutaneous tissue and platysma, raising platysmal flaps. The sternocleidomastoid is then mobilized and divided off the clavicle. The anterior belly of the omohyoid muscle is also divided to obtain better exposure. The scalene fat pad is then separated from its attachments superiorly, inferiorly, and medially, and retracted laterally. The phrenic nerve is then identified at this time in the anterior surface of the anterior scalene muscle, and the anterior scalene’s attachments are cleared off from the first rib. The middle scalene is also divided in similar fashion, and a neurolysis of brachial plexus is performed. At this point, an IC incision is made, and dissection is carried out as described above.
Follow-up details
Recently, we have begun to routinely perform a venogram either concomitantly with the rib resection or scheduled for 2 to 4 weeks after the operation, at which time additional angioplasty may be performed if needed. Patients are typically discharged on anticoagulation for 3 to 6 months. Follow-up typically involves a wound and symptom check visit at 3 to 4 weeks and a 6-month visit with a duplex ultrasound examination to assess vein patency. For patients whose veins are not well characterized on duplex, a computed tomography venogram is obtained. Patients are also referred to and are closely followed by a specialized physical therapist.
Results
Patient characteristics
A total of 76 patients were identified from February 2007 to June 2023. Patients undergoing rib resection for vTOS had a mean age of 36 (±12) years (Table I). Fifty percent were female. Twenty-four percent of patients were active smokers, and 6.5% had been diagnosed with a hypercoagulability disorder. Sixteen percent of our patient population were athletes, and 7.9% had a history of cervical or axillary trauma (Table I).
Table I.
Patient characteristics (N = 76)
| Variable | Value |
|---|---|
| Age, years, mean (SD) | 36 (12) |
| Sex, No. (%) | |
| Female | 38 (50) |
| Male | 38 (50) |
| Ever smoker, No. (%) | 31 (41) |
| Current smoker, No. (%) | 18 (24) |
| BMI, mean (SD) | 25 (4.1) |
| Laterality, No. (%) | |
| Right | 47 (62) |
| Left | 29 (38) |
| Athlete, No. (%) | 12 (16) |
| Hypercoagulability, No. (%) | 5 (6.5) |
| Presenting symptom, No. (%) | |
| Pain | 5 (6.6) |
| Swelling | 71 (93) |
| Symptom duration before intervention, days, median (IQR) | 10 (4-29) |
| History of cervical or axillary trauma, No. (%) | 6 (7.9) |
| Preoperative imaging, No. (%) | |
| US only | 44 (58) |
| CTV only | 5 (6.6) |
| MRV only | 2 (2.6) |
| US/CTV | 15 (20) |
| US/MR | 5 (6.6) |
| All | 5 (6.6) |
| DVT, No. (%) | 68 (90) |
| Preoperative anticoagulation, No. (%) | |
| None | 1 (1.5) |
| Lovenox | 7 (10.3) |
| Warfarin | 22 (32) |
| DOAC | 30 (44) |
| Heparin | 8 (12) |
BMI, Body mass index; CTV, computed tomography venography; DOAC, direct oral anticoagulant; DVT, deep vein thrombosis; IQR, interquartile range; MR, magnetic resonance; MRV, magnetic resonance venography; SD, standard deviation; US, ultrasound.
The primary complaint among most patients was swelling (93%), followed by pain (6.6%) (Table I). The median duration of symptoms was 10 days (interquartile range [IQR]: 4-29 days). The right subclavian vein was more frequently involved (62%) (Table I). Preoperatively, 90% of patients were diagnosed with DVT, with ultrasound examination alone (58%) being the most commonly used modality. For those diagnosed with DVT, 99% were on anticoagulation after thrombolytic therapy and before rib resection (Table I). Direct oral anticoagulants (DOACs) (44%) and warfarin (32%) were the most commonly prescribed agents.
Operative details
Before rib resection, 83% of patients underwent endovascular intervention, with 17% undergoing endovascular intervention at an outside hospital before referral to our institution (Table II). Of those undergoing endovascular intervention, 87% received overnight thrombolytic therapy alone, 57% underwent rheolytic thrombectomy, and 71% underwent angioplasty. After initial thrombolysis and subsequent discharge, only one patient needed repeat lysis before undergoing rib resection (Table II). The median time from initial endovascular intervention to rib resection was 14 days (IQR: 3-49 days). Twenty-five percent of patients underwent rib resection during the same admission as thrombolysis. Rib resection was primarily performed through an IC approach (91%), with some cases from our early experience conducted through a TA approach (6.6%), and some (2.4%) necessitating a paraclavicular approach (Table II). The average operative time was 127 (±57) minutes (Table II).
Table II.
Intraoperative details (N = 76)
| Variable | Value |
|---|---|
| Endovascular intervention, No. (%) | 63 (83) |
| Before presentation at our institution | 13 (17) |
| Lysis | 55 (87) |
| Rheolytic thrombectomy | 36 (57) |
| Angioplasty | 45 (71) |
| Repeat lysis | 1 (1.6) |
| Approach, No. (%) | |
| Transaxillary | 5 (6.6) |
| Infraclavicular | 69 (91) |
| Paraclavicular | 2 (2.4) |
| Time from endovascular intervention to rib resection, days, median (IQR) | 14 (3-49) |
| Rib resection same admission as initial endovascular intervention, No. (%) | 19 (25) |
| Patch angioplasty, No. (%) | 10 (13) |
| OR time, minutes, mean (SD) | 127.2 (58) |
| EBL, mean (SD) | 69.1 (83) |
EBL, Estimated blood loss; IQR, interquartile range; OR, operating room; SD, standard deviation.
Perioperative outcomes
The median length of stay after rib resection was 3 days (IQR: 2-5 days) (Table III). Postoperatively, 14% of patients experienced complications, with bleeding complications (12%) being the most common. The majority of these complications were minor, with only 4% of patients undergoing operative intervention (Table III). There were no perioperative deaths or brachial plexus injuries. When looking at complication rates based on time from lysis to rib resection, patients undergoing rib resection within 30 days of lysis had similar overall (15% vs 14%) and bleeding (12% vs 12%) complication rates to those undergoing resection more than 30 days after lysis (Table III).
Table III.
Perioperative outcomes (N = 76)
| Variable | Value |
|---|---|
| Length of stay, days, median (IQR) | 3 (2-5) |
| Perioperative mortality, No. (%) | 0 (0) |
| Overall (N = 76) | Time from initial endovascular intervention to rib resection |
||
|---|---|---|---|
| ≤30 days (n = 34) | >30 days (n = 42) | ||
| Overall complications, No. (%) | 11 (14) | 5 (15) | 6 (14) |
| Nerve injury | 0 (0) | 0 (0) | 0 (0) |
| Bleeding | 9 (12) | 4 (12) | 5 (12) |
| Pneumothorax | 1 (1.3) | 0 | 1 (2.4) |
| AKI | 1 (1.3) | 1 (2.9) | 0 (0) |
| Requiring return to OR, No. (%) | 3 (3.9) | 1 (2.9) | 2 (4.8) |
AKI, Acute kidney injury; IQR, interquartile range; OR, operating room.
Long-term outcomes
The median follow-up time was 1 year (IQR: 0.25-2 years) (Table III). At the first follow-up visit, 79% reported resolution of symptoms, whereas 93% reported symptom resolution at the last follow-up visit. Postoperatively, 90% of patients were on anticoagulation for a median duration of 4 months (IQR: 3-6 months), with DOACs (45%) and warfarin (43%) being the most commonly prescribed agents (Table IV). At 1 year, 22% of patients underwent reintervention for recurrent stenosis or thrombosis. The median time from rib resection to reintervention was 77 (IQR: 50-126) days (Table IV). Angioplasty (21%) was the most commonly used reintervention, followed by lysis (6.6%) and stenting (2.6%). A total of 5.3% of patients underwent more than one reintervention (Table IV). Vein patency at the last follow-up was 96% for our overall population (Table IV). Patency rate was also similar when stratified based on time from initial endovascular intervention to rib resection (≤30 days vs >30 days), with patency rate of 97% vs 95%, respectively.
Table IV.
One-year outcomes (N = 76)
| Variable | Value |
|---|---|
| Duration of follow-up, years, median (IQR) | 1 (0.25-2) |
| Symptom resolution at first follow-up, No. (%) | 60 (78.9) |
| Symptom resolution at last follow-up, No. (%) | 71 (93.4) |
| Postoperative anticoagulation use, No. (%) | 68 (90) |
| Anticoagulation duration, months, median (IQR) | 4 (3-6) |
| Anticoagulation agents, No. (%) | |
| Lovenox | 2 (2.6) |
| Warfarin | 33 (43.4) |
| DOAC | 34 (44.7) |
| Time to reintervention, days, median (IQR) | 77 (50-126) |
| Overall (N = 76) | Time from initial endovascular intervention to rib resection |
||
|---|---|---|---|
| ≤30 days (n = 34) | >30 days (n = 42) | ||
| Reintervention, No. (%) | 17 (22) | 6 (18) | 11 (26) |
| Reintervention type, No. (%) | |||
| PTA | 16 (21) | 6 (18) | 10 (24) |
| Lysis | 5 (6.6) | 2 (5.9) | 3 (7.1) |
| Stent | 2 (2.6) | 1 (2.9) | 1 (2.3) |
| Multiple reintervention, No. (%) | 4 (5.3) | 3 (8.8) | 1 (2.3) |
| Patency, % | 96 | 97 | 95 |
DOAC, Direct oral anticoagulant; IQR, interquartile range, PTA, percutaneous transluminal angioplasty.
Routine venography
Thirty-four percent of our total patient population underwent routine venography after rib resection. Twenty-seven percent of those were performed during the same admission, whereas the remainder were performed during a separate admission (Table V). Patients receiving routine venography also received interventions 84% of the time. Of those patients, 77% underwent additional angioplasty, and 23% had stents placed at that time (Table V). Unplanned reintervention rates in patients who underwent routine venography were low (12%) compared with those who did not have a follow-up venography after rib resection with a reintervention rate of 28% (Table V). There were no differences in complication rates (15% vs 14%) between patients who underwent routine venography and those who did not.
Table V.
Overview of routine venography
| Routine venography | Value (n = 26) |
|---|---|
| Performed in same admission as rib resection, No. (%) | 7 (27) |
| Performed at separate admission, No. (%) | 19 (73) |
| Intervention performed, No. (%) | 22 (84) |
| Angioplasty only | 17 (77) |
| Stenting | 5 (23) |
| Yes (n = 26) | No (n = 50) | |
|---|---|---|
| Reintervention, No. (%) | 3 (12) | 14 (28) |
| Patency, % | 96 | 96 |
| Complications, No. (%) | 4 (15) | 7 (14) |
Discussion
Although the optimal approach for thoracic outlet decompression continues to be debated, our experience with managing vTOS supports the popularization of the IC approach.18 Our results highlight the efficacy and safety of IC rib resection, as demonstrated by our 96% overall patency rate and 93% symptom resolution and overall low morbidity.
In the initial years of our experience, TA was the preferred method for managing patients with vTOS. Although these cases were successful with only minor complications, our group opted to shift toward IC rib resections because of their capability to provide optimal exposure of the subclavian vein in the costoclavicular space, where the pathology lies. This approach also provides access to the vein more medially and in a shallower surgical field, improving the ease and quality of venolysis and facilitating open repair of the vein when necessary. In addition, the IC approach may confer some benefit in terms of complications. Although studies comparing IC rib resections with other commonly used approaches have demonstrated similar vein patency and symptom resolution across all modalities, the reported complication rates in patients undergoing rib resection via an IC approach tends to be lower, although no direct comparison between all 3 commonly used approaches exists.11, 12, 13, 14, 15 This is particularly evident in the rate of brachial plexus/nerve injuries after rib resections. SC, TA, and PC approaches have been associated with nerve injury rates around 3%, 5%, and 6%, respectively.15,19, 20, 21 Notably, nerve injury is a rarely observed complication with the IC approach.17,18 In our own institutional experience, there have been no nerve injuries with IC rib resections, underscoring the ability to completely avoid manipulation of the brachial plexus with an IC incision. Despite its advantages, the IC approach may be limited in patients present with a mixed nerve and venous TOS etiology. In these cases, we employ and recommend a PC approach to ensure adequate neurolysis.
First proposed in 1989, the use of thrombolysis followed by decompression is now widely accepted as the standard of care for patients with Paget-Schroetter syndrome, given that anticoagulation alone has been associated with higher rates of recurrent thrombosis.22, 23, 24 However, there is still some debate in terms of optimal time between lysis and rib resection. Historically, it was recommended to postpone surgical intervention for approximately 6 to 12 weeks after lysis to mitigate the risk of bleeding and allow for the vein to “settle” after acute inflammatory state induced by thrombosis.25 Recent data, however, suggest that early decompression is as safe and effective as delayed intervention and, in some instances, decreases the incidence of recurrent thrombosis.26,27 Drawing from our experience and the results of these studies, we have elected to typically perform decompression within 30 days of lysis. Our outcomes are consistent with other studies supporting early decompression. In our overall cohort, we have observed high patency rates, with only nine patients experiencing any bleeding-related complications and three requiring intervention. Furthermore, we did not see any evidence of increased complications, bleeding or otherwise, in patients undergoing rib resection within 30 days compared with those who waited longer for decompression. In addition, in the period between lysis and rib resection, only one patient underwent repeat lysis before undergoing scheduled rib resection.
With the continued implementation and increased comfort with endovascular interventions, we have also experienced an evolution in our approach of addressing residual subclavian stenosis after lysis. Among the patients in our cohort, a total of 10 underwent vein patching or reconstruction; however, since 2014, only one patient underwent vein patching. This reflects a shift from aggressively addressing luminal narrowing during decompression toward opting to evaluate vessel stenosis either immediately after rib resection or within 2 to 4 weeks during routine venography before intervening. At that time, any residual stenosis can be adequately addressed through angioplasty, yielding excellent results. This was performed in 22% of our overall patient population, and we have seen no indication of differing patency rates in this group compared with our earlier experience in patients undergoing vein patch or reconstruction. This aligns with results by other groups demonstrating the usefulness of angioplasty in this setting.28,29 Similarly, we have opted to minimize stent placement. Although we were more likely to place stents (total of five patients) for significant residual stenosis in our earlier experience, we have since opted to preferentially perform angioplasty and let the vein settle on anticoagulation before committing to stents. As a result, since 2013, no stents have been placed in the management of acute vTOS. This is likely the preferred approach as stent fractures and recurrent thrombosis have been reported after subclavian vein stenting.30,31 Furthermore, the use of routine venography with additional interventions as needed resulted in a reduction in symptomatic restenosis/occlusion requiring reintervention. Although 28% of patients who did not undergo routine venography underwent reintervention due to recurrence of symptoms, only three patients (12%) of the routine venography population needed any additional intervention. Although we recognize that the cost and risk of venography are inherently higher than those of a duplex, this is largely offset by the reduction in restenosis, seen in both our series and others.28 This decreases the need for potentially more complex reinterventions at a later time point. This may be a result of a more efficient venoplasty, which allows for the full expansion of the vein once the sclerotic sheath has been adequately removed. These results have led to our decision to incorporate routine venography as part of our postoperative management of vTOS.
Conclusions
In the absence of definitive evidence favoring one surgical approach over another, our experience with the IC approach for isolated vTOS, characterized by low perioperative morbidity and favorable patency rates, lends support to the adoption of the IC approach with adjunct endovascular techniques as a safe and efficacious treatment for vTOS.
Author Contributions
Conception and design: LM, JT, SY, AL, PL, AH, MW, MS, LS
Analysis and interpretation: LM, MS, LS
Data collection: LM, JT
Writing the article: LM, LS
Critical revision of the article: LM, JT, SY, AL, PL, AH, MW, MS, LS
Final approval of the article: LM, JT, SY, AL, PL, AH, MW, MS, LS
Statistical analysis: LM
Obtained funding: Not applicable
Overall responsibility: LS
Funding
L.M. is supported by the National Institutes of Health T32 Grant 5T32HL007734. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
Disclosures
None.
From the Society for Clinical 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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