Primary Axillary-Subclavian Venous Thrombosis: Is Aggressive Surgical Intervention Justified?

Abstract

Multimodal (thrombolysis, surgical decompression, venous reconstruction, oral anticoagulation) treatment of primary axillary-subclavian venous thrombosis was reviewed to assess the impact of venous patency on functional outcome. Since 1996, 7 patients (6 men, 1 woman) of ages 16-53 years (mean 33 years) presented with symptomatic acute axillosubclavian venous thrombosis as a result of a recent athletic or strenuous arm activity. Five patients had undergone previous (>2 weeks) catheter-directed thrombolysis and venous angioplasty. Diagnostic contrast venography followed by repeat catheter-directed thrombolysis demonstrated abnormal (residual stenosis [n =6] or occlusion En = I1) axillosubclavian venous segments in all patients. Surgical intervention was performed at a mean interval of 7 days (range 1-19 days) after thrombolysis and consisted of thoracic outlet decompression with scalenectomy and 1st rib resection via a paraclavicular (n =4) or supraclavicular (n = 3) approach. Medial claviculectomy or cervical rib resection was performed in 2 patients. Concomitant venous surgery was performed in all patients to restore normal venous patency by circumferential venolysis (n = 7) and balloon catheter thrombectomy (n = 3), or vein-patch angioplasty (n=2), or endovenectomy (n=5), or internal jugular transposition (n=2). Postoperative venous duplex testing beyond 1 month identified recurrent thrombosis in 4 patients despite therapeutic oral anticoagulation. Subsequent venous recanalization was documented in 3 patients. Poor functional outcome was associated with an occluded venous repair and extensive venous thrombosis on initial presentation. A patent or recanalized venous repair present in 6 of 7 patients was associated with good functional outcome and may justify multimodal intervention in patients with primary axillosubclavian effort thrombosis presenting with recurrent thrombosis and significant residual disease after thrombolysis.

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