Surgical management of post-thrombotic syndrome in chronic venous thoracic outlet syndrome

Abstract

ObjectiveVenous thoracic outlet syndrome (VTOS) is considered chronic when symptoms and venous stenosis or occlusion are present for >3 months after the initial primary upper extremity deep vein thrombosis event. Many of patients with chronic VTOS receive conservative treatment. However, a subset of these patients will have persistent post-thrombotic syndrome symptoms because of underlying causative anatomy. We present the results of a same admission treatment consisting of' transaxillary thoracic outlet decompression (TA-TOD), external venolysis, and, if necessary, treatment of residual intraluminal lesions with percutaneous transluminal angioplasty (PTA) for chronic VTOS. MethodsAll patients presenting from January 2015 to December 2019 with chronic VTOS and post-thrombotic syndrome complaints were evaluated. Patients with some degree of patency on venography or a chronic occlusion that could be recanalized using PTA preoperatively underwent TA-TOD, external venolysis, and immediate venography. Low-pressure diagnostic balloon inflation after first rib resection was used to identify residual lesions not evident by venography. If found, PTA was performed. Stent placement was reserved for patients with recurrent complaints due to residual lesions that had not been effectively treated by PTA. ResultsA total of 40 patients with chronic VTOS were evaluated, of whom 36 were included and treated according to the protocol. The remaining four patients had had a chronic occlusion that could not be recanalized preoperatively and these patients were, therefore, excluded. After TA-TOD, immediate venography showed patent vessels with residual stenosis in 31 patients. Of the five patients who had appeared to have no significant stenosis on venography, two showed narrowing with diagnostic balloon inflation of the subclavian vein, for a total of 33 patients (92%) with residual stenosis after TA-TOD. All 33 patients underwent formal venous PTA. Complications occurred in five patients. At a mean follow-up of 24 months, 30 of the 36 patients (83%) were free of symptoms. The mean thoracic outlet syndrome disability scale score was 1.97 ± 1.9. The mean Disability of the Arm Shoulder and Hand scale score was 16.16 ± 17.4. The median VEINES (venous insufficiency epidemiologic and economic study)-symptoms score was 53.90 (interquartile range, 10.54). The median VEINES-quality of life (QOL) score was 54.22 (interquartile range, 13.93). Finally, the mean 12-item short-form physical QOL component scale score was 47.97 ± 9.02. The thoracic outlet syndrome disability scale and Disability of the Arm Shoulder and Hand scale scores had significantly decreased (P < .01), and the 12-item short-form physical QOL component scale score had significantly improved (P < .01) compared with the baseline scores. A return to daily activities was achieved by 93% of the patients. ConclusionsThe treatment of patients with chronic VTOS using a same admission treatment algorithm consisting of TA-TOD, external venolysis, and PTA is effective. Intermediate follow-up showed a high return to daily activity and significant improvement in functional outcome and physical QOL.