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Abstract

Dr. Molina emphasizes in his letter that an awareness of “effort thrombosis” may result in more operations to treat the condition. Although we too remain optimistic, we believe that aggressive intervention with lytic therapy will unmask the cause of the venous thrombosis and allow definitive surgical treatment at the level of the first rib. The protocol cited in Dr. Molinas' publication is essentially the same as that outlined in our article except for the use of arm compression and balloon angioplasty, which have not been required to date. The compression of the subclavian vein between paravenous soft-tissue structures (subclavian and anterior scalene muscles) and the first rib results in reduced flow, stenosis, and eventually thrombosis, probably on damaged intima. The circumferential venous scarring surrounding the vein is the sequelae that we observed and diligently removed by venolysis as described in our article. Dr. Molina thinks that this fibrotic tissue does not cause the obstruction alone. He may be right, but the severe unyielding deformity of the vein lumen that results is certainly a major cause of thrombosis and, particularly, rethrombosis if not removed in chronic cases. Although there was some residual deformity as pointed out, neither that patient nor any others have had further problems of venous thrombosis. Finally, when patients are managed in the acute setting, lysis and immediate surgery may be recommended. Our patients, however, underwent early treatment in another community hospital and were later referred for treatment. Dr. Molina's article and our publication served to emphasize the importance of a surgical cause for effort venous thrombosis of the upper extremity and combine lytic therapy and surgery effectively. 24/41/46018