Hybrid Paraclavicular Decompression for Venous Thoracic Outlet Syndrome with Primary Endovascular Reconstruction

Abstract

Venous thoracic outlet syndrome (vTOS) is characterized by severe stenosis and potential thrombosis of the axillary-subclavian vein (effort thrombosis) with significant effects on patient mobility, quality of life, and risks associated with possible anticoagulation. Treatment goals are aimed at symptomatic improvement and freedom from recurrent thrombosis. To date, there exists no clear protocols or recommendations on surgical approach that results in optimal outcomes. We highlight our institution's experience with a systematized, paraclavicular approach with intraoperative balloon angioplasty only, if needed. This was a retrospective case series identifying 33 patients that underwent thoracic outlet decompression for vTOS from 2014-2021 via paraclavicular approach at Trinity Health Ann Arbor. Demographics, presenting symptoms, perioperative details, and follow-up details describing symptomatic improvement and imaging surveillance were obtained. The average age of our patients was 37 with the most common presenting symptoms of pain and swelling (91%). The average time from diagnosis to thrombolysis for effort thrombosis was 4 days, with an average time to operative intervention of 46 days. All patients underwent a paraclavicular approach with full first rib resection, anterior and middle scalenectomy, subclavian vein venolysis, and intra-operative venogram. Of these, 20 (61%) underwent endovascular balloon angioplasty, one required balloon with stent placement, 13 (39%) required no additional intervention, and no patients required surgical reconstruction of the subclavian-axillary vein. Duplex imaging was used to evaluate recurrence in 26 patients at an average of 6 months post-op. Of these, 23 demonstrated complete patency (89%), one demonstrated chronic non-occlusive thrombus, and two demonstrated chronic occlusive thrombus. Almost all our patients (97%) had moderate or significant improvement of their symptoms. None of our patients required a subsequent operation for recurrence of symptomatic thrombosis. The mode length of anticoagulation use post-operatively was 3 months, with an average use of 4.5 months. A systematized surgical approach of paraclavicular decompression for venous thoracic outlet syndrome with primary endovascular balloon angioplasty carries minimal morbidity with excellent functional results and symptomatic relief.