Regarding “Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty”
2005; Elsevier BV; Volume: 42; Issue: 3 Linguagem: Inglês
10.1016/j.jvs.2004.11.043
ISSN1097-6809
Autores Tópico(s)Peripheral Nerve Disorders
ResumoI read with interest the work by Schneider et al titled “Combination Treatment of Venous Thoracic Outlet Syndrome: Open Surgical Decompression and Intraoperative Angioplasty.”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 (108) Google Scholar 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.2Molina J.E. Surgery for effort thrombosis of the subclavian vein.J Thorac Cardiovasc Surg. 1992; 103: 341-346PubMed Google Scholar, 3Molina J.E. Operative technique for first rib resections via subclavicular approach.Vasc Surg. 1993; 27: 667-672Crossref Scopus (15) Google Scholar, 4Molina J.E. Need for emergency treatment in subclavian view effort thrombosis.J Am Coll Surg. 1995; 181: 414-420PubMed Google Scholar 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. I do use venography only before surgery to assess the degree of stricture of the vein after thrombolysis. I believe that our approach is superior because there is no need to perform a supraclavicular incision to gain access to the subclavian vein. In fact, I believe that removal of the first rib alone with scalenectomy cannot adequately treat a vein stricture that is caused by fibrosis of the vein wall itself. The vein needs to be enlarged, and I do this during the same operation by using a segment of saphenous vein. It is almost predictable that some of the subclavian veins treated with balloon angioplasty alone will rethrombose. In the experience of Schneider et al, 8% of them did so, and this required further reintervention to treat the obstruction. I believe that dilation of a fibrotic vein will lead invariably to more fibrosis because of the tears that the balloon will cause on the fibrotic tissue already existent in the vein. At the end of the thrombolytic treatment used by Schneider et al, 64% of their patients had identifiable fibrous vein strictures and were treated with balloon angioplasty. In our series of more than 130 patients treated with my technique, the patency rate continues to be 100% with 15 years of follow-up, without the need for balloon angioplasty. My technique for treating acute and subacute subclavian vein obstruction has been extended to treat chronic obstructions5Molina J.E. Treatment of chronic obstruction of the axillary, subclavian and innominate veins.Int J Angiol. 1999; 8: 87-90Crossref Scopus (9) Google Scholar, 6Molina J.E. A new surgical approach to the innominate and subclavian vein.J Vasc Surg. 1998; 27: 576-581Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 7Molina J.E. Use of cryopreserved small aortic homografts for large vein replacement.J Vasc Surg. 1999; 33: 545-555Crossref Scopus (5) Google Scholar, 8Molina J.E. Approach to the confluence of the subclavian and internal jugular veins without claviculectomy.Semin Vasc Surg. 2000; 13: 10-19PubMed Google Scholar with equal success. I was surprised that my publications were not discussed by Schneider et al and wonder whether they have considered this alternative approach, which I believe to be superior. Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplastyJournal of Vascular SurgeryVol. 40Issue 4PreviewResidual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 42Issue 3PreviewWe appreciate Dr Molina’s interest in our article,1 and we recognize his contributions to the literature regarding the treatment of venous thoracic outlet syndrome. Full-Text PDF Open Archive
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