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Infraclavicular First Rib Resection for the Treatment of Acute Venous Thoracic Outlet Syndrome
Jeffrey J. Siracuse, M.D., Paul C. Johnson, M.D., Douglas W. Jones, M.D., Gregory G. Salzler, M.D., Heather L. Gill, M.D., Andrew J. Meltzer, M.D., Peter H. Connolly, M.D., Darren B. Schneider, M.D..
New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.

OBJECTIVES: Venous thoracic outlet syndrome (VTOS) most commonly is treated by transaxillary, supraclavicular, or paraclavicular approaches based on surgeon preference. However, we have adopted an infraclavicular approach to VTOS as the surgical pathology is in the anterior costoclavicular space. We hypothesize that this approach for thoracic outlet decompression provides excellent access to the costoclavicular space and the axillosubclavian veins for safe and effective treatment of patients with an acute presentation of VTOS.
METHODS: We retrospectively reviewed all consecutive patients that underwent infraclavicular thoracic outlet decompression for an acute presentation of VTOS from July 2005 to February 2014 by a single surgeon. Acute presentation was defined as less than 14 days between the onset of symptoms and catheter directed thrombolysis (CDT). Demographics, primary and secondary subclavian vein patency, perioperative outcomes, and reinterventions were recorded.
RESULTS: 30 patients underwent an infraclavicular approach for treatment of VTOS. Average age was 33 and 60% were male. All patients underwent CDT and subsequent infraclavicular first rib resection and intraoperative venography, which was technically successful in all patients. Intraoperative subclavian vein angioplasty was performed in 70%. Median postoperative length of stay was 2 days (range 2-6), blood loss was 75 ml (20-200), and operative time was 117 minutes (76-166). Median follow-up was 78 days (2-483). Ultrasound at follow-up was performed on 24/30 (80%) with all patients having patent subclavian veins at last follow-up. Reinterventions included 2 cases for rethrombosis and one case of hemothorax. There were no complications of brachial plexus or phrenic nerve injury. All patients at last follow up were symptom free and subclavian veins were patent.
CONCLUSIONS: An infraclavicular approach is a safe and effective treatment for acute VTOS. It provides excellent access to the costoclavicular space for first rib resection and subclavian venolysis while at the same time minimizing the risk of brachial plexus and phrenic nerve injury.

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