Outcomes Following Interval Delayed First Rib Resection For Axillosubclavian DVT
Prem J. Minchu, BS1, Morgan Messner, NP-BC2, Francisco Albuquerque, MD2, Daniel Newton, MD2, Robert Larson, MD2, Mark Levy, MD2.
1VCU School of Medicine, RICHMOND, VA, USA, 2VCU Health Department of Vascular Surgery, RICHMOND, VA, USA.
OBJECTIVE - The current management of axillosubclavian deep vein thrombosis (DVT) often utilizes thrombolysis for the DVT, prompt first rib removal, and occasional venoplasty or stenting. Our institution has increasingly utilized anticoagulation alone followed by interval first rib resection. We sought to analyze the effectiveness of this simplified technique.
METHODS - Between September 2012 and April 2021, 27 patients were identified within the institution’s electronic medical record using the current procedural terminology code for first rib resection and diagnosis code for upper extremity DVT. Seven patients that had undergone preoperative thrombolysis were excluded. Among the remaining 20 patients, preoperative clinic charts were evaluated for age, venous segment involvement, contralateral involvement, presence of documented hypercoagulable state, duration of pre- and post-operative anticoagulation, and complications.
RESULTS - Of the 20 patients (mean age 26.2 years, 13 males) presenting with axillosubclavian DVT treated with first rib resection, all patients presented with right (n=8) or left (n=12) arm swelling. Two patients were on oral contraceptives and no patients had any other defined hypercoagulable conditions. The mean (± SD) duration of pre- and post-operative anticoagulation was 3.2 ± 2.6 months and 2.1 ± 2.1 months respectively. Nineteen patients underwent supraclavicular first rib resection and 1 patient underwent transaxillary resection. Twelve (60%) patients demonstrated complete DVT resolution by venous duplex examination during the post-operative period and 8 (40%) patients demonstrated partial recanalization/chronic DVT. Complications included 1 hemothorax and 1 thoracic duct injury. All twenty patients remain asymptomatic without arm swelling to date, with a mean follow-up of 55.1 ± 34.7 months.
CONCLUSIONS - Anticoagulation alone followed by interval first rib resection proved to be successful in alleviating symptomatic axillosubclavian DVT for effort thrombosis in the short to medium term. By eliminating the need for venograms or thrombolysis, this algorithm simplifies our management for venous thoracic outlet syndrome while maintaining good clinical outcomes. This study only analyzed our management algorithm’s effectiveness in the short to medium term. The long-term effectiveness of this treatment will need to be analyzed.
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