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Society For Clinical Vascular Surgery

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Is Stenting in Venous Thoracic Outlet Syndrome Truly Necessary?
Joseph Inhofer, David Dexter, Noel Parent, Animesh Rathore, Jonathan Swisher, Jean Panneton.
Eastern Virginia Medical School, Norfolk, VA, USA.

OBJECTIVES: Traditionally, venous thoracic outlet syndrome (TOS) is treated using an algorithm that includes a combination of venous thrombolysis, first rib resection (FRR) and venous angioplasty. Venous stenting after FRR is controversial and has been associated with higher rates of post-procedural subclavian vein thrombosis. We present our outcomes with a strategy of selective venous stenting after FRR.
METHODS: We performed a retrospective review within five hospitals of patients diagnosed with venous TOS between January 2012 and April 2017. We included patients who underwent FRR with our without adjuvant venous thrombolysis. A strategy of selective subclavian vein stenting was undertaken where all patients who underwent FRR had a venogram during the same operative setting. All patients with residual subclavian vein stenosis underwent venous angioplasty. Lesions that did not achieve a satisfactory result received a subclavian vein stent. Our primary endpoints were technical success and subclavian vein patency. Statistical analysis was carried out using SPSS (IBM Armonk, NY).
RESULTS: We identified 35 patients who underwent 36 FRR for venous TOS. The mean age was 34.7 years, the majority were females (24/36, 67%), and the mean BMI was 23.87. We identified 28 extremities with subclavian vein thrombosis, 5 extremities with symptoms of venous compression without DVT and 3 extremities with a dialysis circuit with symptoms of stenosis at the subclavian vein. All patients underwent venogram. A normal venogram was identified in 27.8% (10 of 36), venoplasty was performed in 72.2% (26 of 36) and a stent for residual stenosis was required in 41.7% (15 of 36). We had a mean follow up of 12.5 months. No patients who underwent diagnostic venogram or venoplasty had a postoperative axillo-subclavian thrombosis. We identified one patient who received a stent that developed a postoperative axillo-subclavian thrombosis.
CONCLUSIONS: We present our outcomes with a strategy of selective subclavian vein stenting after FRR. The postoperative success rate of our strategy was 97.2%. This rate compares favorably to the opposing options of venoplasty alone or open venous reconstruction after FRR. We conclude that a strategy of stenting residual lesions after failed angioplasty can provide an excellent result in patients with venous TOS.

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