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Circumferential venolysis and paraclavicular thoracic outlet decompression for effort thrombosis of the subclavian vein

1993; Elsevier BV; Volume: 17; Issue: 6 Linguagem: Inglês

10.1016/0741-5214(93)90732-2

1097-6809

Robert W. Thompson, Peter A. Schneider, Nicolas A. Nelken, Claes G. Skiöldebrand, Ronald J. Stoney,

Diagnosis and Treatment of Venous Diseases

The report made by Thompson et al. (J VASC SURG 1992;16:723-32) regarding “effort thrombosis” of the subclavian vein contributes to make all physicians aware of this problem for which the treatment in the past has been largely ineffective, untimely, and ill guided. Awareness of effort thrombosis of the subclavian vein may lead to more frequent diagnosis of the acute condition, which invariably will lead to more frequent operations, and it is important that the proper operation is done to relieve the true mechanism of the obstruction. The article reports only six cases for which no more than four patients underwent the same type of treatment. Our experience with this syndrome initially reported 28 patients.1 As I indicated in that publication, we have a standard protocol to treat this problem. What I do not find in the report of Thompson et al. is the recognition of the pinching mechanism that leads to vein thrombosis at the thoracic inlet. When these patients are operated on in the acute stage, as clearly indicated in our publication, the main components of the pinching are the subclavius muscle and the fibers of the anterior scalene muscle tendon. Our experience has accumulated 35 patients, all treated with the same protocol of urokinase and lysis of the thrombus, followed by surgery as soon as the clot has been dissolved (usually within 24 hours). The operation uses exclusively subclavicular approach, as described in detail in our publication. All require excision of the subclavius tendon and the tendon of the anterior scalene muscle. The fibrotic tissue around the vein does not, by itself, cause the obstruction. Severe trauma to the vein always results in fibrosis of the vessel wall with obstruction, which in our series has required either balloon angioplasty or patch angioplasty. Examining the vein only externally at the time of surgery is misleading because often enough the obstruction is in the intimal layer with severe fibrosis and sometimes total obliteration of the venous channel for several centimeters. Although some patients, such as the ones reported by Thompson et al., had thrombosis that cleared with thrombolytic therapy without development of fibrotic stricture of the vein, most of them, if more than 1 week old, do have stricture. Confirmation to my above statements is the fact that in the study of Thompson et al. significant stricture of the vein remains. The patient may feel better, but the vein does not have normal caliber. Because none of our patients operated on in the acute or subacute stage (13 patients) had complications or persistent stenosis (a success rate of 100%), we strongly recommend that the protocol with thrombolytic agents, immediately followed by surgery, should be undertaken as soon as possible and on an emergency basis before fibrosis and obliteration of the vein occur. 24/41/46017