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OBJECTIVES:
Management of deep vein thrombosis (DVT) of the upper extremity due to thoracic outlet syndrome (TOS) compressing the subclavian vein and of the lower extremity due to iliac vein stenosis remains controversial. We reviewed our evolving strategies during the last decade or so to treat these challenging patients.
METHODS:
Between 1998-2011, we treated 31 patients with 18 subclavian DVTs (all due to TOS) and 13 iliac DVTs (most due to right iliac artery compression). Management early in the series included prolonged catheter-directed thrombolysis compared to increased use of mechanical thrombolysis since 2006. Patients with TOS early in the series were treated with total excision of the first rib using combined supra- and infra-clavicular incisions, while excision of only the anterior half of the rib via an infra-clavicular incision was utilized l since 2006. Patients early in the series were infrequently treated with stenting compared to more recent cases. Patients with thrombus originating in the popliteal vein and extending proximally were treated via catheter insertion into the popliteal vein more recently compared to femoral vein puncture earlier. Anticoagulation with heparin and then Coumadin for six months was routinely administered to all patients. Patients were followed with serial duplex ultrasounds (follow up, 6 months - 13 years )
RESULTS:
There was no major morbidity or mortality in these 31 patients. Three patients developed recurrent DVT (1/13 iliac; 2/18 subclavian) but experienced continued long-term venous patency after further treatment. Length of treatment and length of stay was shorter using our revised strategy.
CONCLUSIONS:
Increasing use of mechanical thrombolysis has led to shorter treatment duration and length of hospital stay in this series. Limiting first rib resection to the anterior half of the rib in patients with TOS shortened operative time and minimized chances of brachial nerve injury without negative impact on recurrent subclavian vein stenosis. In patients with venous TOS and iliac vein stenosis, stenting of subclavian and iliac veins to treat residual stenosis following balloon angioplasty has excellent long term patency rates in this series.