Long-term Follow Up Of Central Venous Bypass For Salvage After Failed Stenting For Venous Thoracic Outlet Syndrome (vTOS)
Alveena Ahmed, Oonagh Scallan, MD, FRCSC, Audra Duncan, MD, FACS, FRCSC.
Western University, London, ON, Canada.
DEMOGRAPHICS: 53-year-old healthy male paramedic presented with significant right arm swelling and pain. HISTORY: The patient developed a right axillosubclavian deep vein thrombosis in 2011. At an outside hospital, he underwent catheter-directed thrombolysis and stenting of the subclavian vein without rib resection. Over the next 5 years his symptoms recurred prompting multiple venoplasties and stenting for in-stent stenosis and stent fracture. In 2016 he was referred to our tertiary care center. Contrast venography (Fig 1A) and CT demonstrated stenosis of the stent, with occlusion upon arm abduction. Transaxillary first rib resection, and scalenectomies were performed with concomitant high-pressure balloon venoplasty of the stents. The patient was anticoagulated. Three months later, the stents reoccluded and were successfully recanalized with thrombolysis, venoplasty, and relining with two 8mm Viabahn stents. Despite this, the patient had ongoing venous stenosis with debilitating symptoms of venous hypertension and was unable to work. PLAN: A central venous bypass was performed using right femoral vein. The right axillary vein adjacent to the stent was exposed through an infraclavicular incision and the left innominate vein through a sternotomy. The left innominate vein was selected as outflow because the proximal stent encroached on the right innominate vein. A 10mm externally supported PTFE graft was tunneled from the infraclavicular incision through the 3rd intercostal space, and the vein graft placed within the PTFE. The vein graft was sutured end-to-side to the innominate vein, then end-to-side to the axillary vein. The pressure gradient from the axillary to the innominate prior to the bypass was 13mmHg, and reduced to 1mmHg post-bypass. The patient had no postoperative complications, and had excellent symptomatic relief. Five year follow-up demonstrates patency of the bypass. (Fig 1B) DISCUSSION: Venous stenting for vTOS in the absence of rib resection is high-risk for stent complications including fracture and occlusion. This case demonstrates a technique for venous decompression in a good risk patient using femoral vein tunneled within PTFE graft through a sternotomy to provide long-term patency and good functional outcome. 
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