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Abstract

We appreciate Dr Molina’s interest in our article,1Schneider D.B. Dimuzio P.J. Martin N.D. Gordon R.L. Wilson M.W. Laberge J.M. et al.Combination treatment of venous thoracic outlet syndrome open surgical decompression and intraoperative angioplasty.J Vasc Surg. 2004; 40: 599-603Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar and we recognize his contributions to the literature regarding the treatment of venous thoracic outlet syndrome. We agree with Dr Molina that claviculectomy is unnecessary and that subclavian vein decompression may be performed through an infraclavicular incision. The last two patients in our recent series underwent decompression through an infraclavicular incision, and this is now our preferred approach.1Schneider D.B. Dimuzio P.J. Martin N.D. Gordon R.L. Wilson M.W. Laberge J.M. et al.Combination treatment of venous thoracic outlet syndrome open surgical decompression and intraoperative angioplasty.J Vasc Surg. 2004; 40: 599-603Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar However, we do not agree that vein patch angioplasty is necessary to achieve durable subclavian vein patency and that percutaneous subclavian vein angioplasty after surgical decompression “will lead invariably to more fibrosis,” as Dr Molina contends in his letter. To the contrary, our results suggest that surgical decompression followed by percutaneous angioplasty is safe and effective, resulting in 92% 1-year objective primary patency.1Schneider D.B. Dimuzio P.J. Martin N.D. Gordon R.L. Wilson M.W. Laberge J.M. et al.Combination treatment of venous thoracic outlet syndrome open surgical decompression and intraoperative angioplasty.J Vasc Surg. 2004; 40: 599-603Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Rethrombosis occurred in two patients in our series and was an early postoperative event likely related to extensive venous disease present at the time of treatment and not to the later development of fibrosis. Dr Molina’s own experience2Molina J.E. Surgery for effort thrombosis of the subclavian vein.J Thorac Cardiovasc Surg. 1992; 103: 341-346PubMed Google Scholar, 3Molina J.E. Need for emergency treatment in subclavian vein effort thrombosis.J Am Coll Surg. 1995; 181: 414-420PubMed Google Scholar with open surgical subclavian vein reconstruction for lesions longer than 2.5 or 2 cm with patency rates of 25% and 37.5%, respectively, indicates that patency is arguably more a function of lesion extent and chronicity than of the technique used to treat a residual subclavian vein stenosis. Finally, it seems that Dr Molina has successfully used percutaneous angioplasty to treat residual subclavian vein stenosis after both surgical subclavian vein decompression2Molina J.E. Surgery for effort thrombosis of the subclavian vein.J Thorac Cardiovasc Surg. 1992; 103: 341-346PubMed Google Scholar and surgical subclavian vein decompression with vein patch angioplasty, with durable success.3Molina J.E. Need for emergency treatment in subclavian vein effort thrombosis.J Am Coll Surg. 1995; 181: 414-420PubMed Google Scholar Indeed, our similar favorable experiences with postoperative subclavian vein angioplasty led us to adopt our current approach of subclavian vein decompression and intraoperative angioplasty, which we believe to be the optimal treatment for venous thoracic outlet syndrome. Regarding “Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty”Journal of Vascular SurgeryVol. 42Issue 3PreviewI read with interest the work by Schneider et al titled “Combination Treatment of Venous Thoracic Outlet Syndrome: Open Surgical Decompression and Intraoperative Angioplasty.”1 The authors report the treatment of 25 patients with first-rib resection and intraoperative balloon angioplasty of the subclavian vein. In contrast to this approach, I prefer decompressing the subclavian vein through a subclavicular incision and enlarging the caliber of the vein with a vein patch.2-4 Our approach also involves a single operation and has resulted in 100% patency without the need for venography or balloon angioplasty in the operating room. Full-Text PDF Open Archive