Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis

Background: Axillosubclavian vein thrombosis, also known as Paget-Schroetter syndrome, is a rare presentation of thoracic outlet syndrome (TOS) representing approximately 5% of all cases. Conventional management consists of routine anticoagulation, operative decompression via first rib resection and scalenectomy (FRRS), and, recently, thrombolysis. The purpose of our study was to retrospectively review our experience with this condition and compare the effectiveness of preoperative endovascular intervention with thrombolysis and venoplasty to anticoagulation alone in those undergoing FRRS to preserve subclavian vein patency. Methods: A retrospective review was conducted for all venous TOS patients from July 2003 to May 2009 from a prospectively maintained database. Preoperative clinic notes were reviewed to allow stratification into two groups. One group consisted of patients undergoing preoperative endovascular intervention with thrombolysis and venoplasty, while the other group consisted of patients managed medically with anticoagulation alone prior to FRSS. Operative notes, postoperative venograms, and postoperative duplex imaging results were reviewed for presence of recanalization, chronic nonocclusive thrombus, or continued occlusion. Results: One hundred three patients had 110 FRRS for subclavian vein thrombosis (53 men, 50 women), seven of which had contralateral FRRS for thrombosis. The cohort averaged 31 years of age (range, 16-54 years) with an overall, mean follow-up time of 16 months (range, 1-52 months). Of the 110 veins evaluated, 45 underwent endovascular intervention (thombolysis, with or without venoplasty) prior to FRRS, and at 1 year, 41 (91%) were patent with improvement of symptoms. In the 65 veins on anticoagulation alone, 59 (91%) ultimately were patent, with symptomatic improvement in all. Overall, 91% (100/110) of subclavian veins were patent in patients completing follow-up, were asymptomatic, and back to their previous active lifestyle. Conclusions: Preoperative endovascular intervention offered no benefit over simple anticoagulation prior to FRRS, since the use of thrombolysis prior to FRRS, regardless of need for postoperative venoplasty, had little impact on overall rates of patency. The optimal treatment algorithm may merely be routine anticoagulation for all effort thrombosis patients prior to FRRS followed by venography with venoplasty if needed. The role of thrombolysis for Paget-Schroetter syndrome should be further investigated in randomized trials.