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Simple extra-anatomic jugular vein bypass for subclavian vein thrombosis

1985; Elsevier BV; Volume: 2; Issue: 6 Linguagem: Inglês

10.1016/0741-5214(85)90145-4

1097-6809

Barbara Hansen, Robert S. Feins, Don E. Detmer,

Vascular Procedures and Complications

Upper extremity venous occlusion can pose special therapeutic problems for the patient and the surgeon. Occlusions frequently occur in young, active people and fall under the heading of “effort” thrombosis.1DeWeese JA Adams JT Gaiser DL. Subclavian venous thrombectomy.Circulation. 1970; 16: 158Google Scholar, 2Drapanas T Curran WL Thrombectomy in the treatment of “effort” thrombosis of the axillary and subclavian veins.J Trauma. 1966; 6: 7Crossref Scopus (52) Google Scholar The acute symptoms typically resolve with conservative therapy (e.g., anticoagulation and elevation). However, the late sequelae of pain, swelling, and weakness may recur with activity, leaving the patient incapacitated and often lost to follow-up. One of the problems of this condition is the incomplete data on its natural history. Few simple alternatives have been available for the late management of this disorder. Surgical procedures to date include decompression of the thoracic outlet and/or venous reconstruction or bypass. A case is presented of subclavian vein thrombosis that was successfully and simply bypassed by an anastomosis of the external jugular vein to the patent peripheral subclavian vein with a saphenous interposition graft. The patient was a 17-year-old girl referred to us for evaluation of chronic arm tightness, swelling, and cyanosis. Thirteen months earlier she had been kicked by a horse in the right inner upper brachium and subsequently developed an axillary vein thrombosis, which had been treated by her local physician by observation and elevation of the right arm. Neither venography nor heparinization had been undertaken initially. The thrombosis and pain resolved spontaneously and she did well for 3 months. At that time she noted that with exercise her arm became blue and felt tight. Her local doctor prescribed three aspirin a day but this brought no permanent relief. The problem persisted for 10 months and since her dominant arm was involved, it caused significant disability. Brachial and subclavian venograms showed two high-grade stenotic webs in the middle portion of the right subclavian vein (Fig. 1, A).History, physical examination, and venograms demonstrated no evidence of thoracic outlet impingement of the nerves, artery, or vein. After through evaluation the patient underwent a procedure to bypass the stenoses. Intraoperative venography demonstrated that dye flowed freely from the external jugular vein into the brachiocephalic vein. The external jugular vein was divided below the angle of the jaw and the caudad segment swung down over the clavicle. The external jugular vein was dissected to the angle of the jaw but became too small in diameter to swing down to the patent axillary vein. It was therefore divided at its midportion and its caudad segment anastomosed to the proximal axillary vein via a saphenous vein end-to-end interposition graft (2.5 cm) (Fig. 1, B). An arteriovenous fistula was created at the wrist and was closed 8 weeks later on an outpatient basis. The patient was given heparin for 72 hours and discharged on the third postoperative day. She received 325 mg of aspirin a day until the fistula was closed and then all medication was discontinued. She has remained symptom-free for 12 months despite a return to heavy exercise. Venograms done at 2 months after operation confirmed unobstructed flow into the jugular vein and superior vena cava. Doppler evaluations postoperatively have continued to confirm patency. Two small cosmetically acceptable scars are present on the neck and chest. Deep venous thrombosis of the upper extremity remains a poorly understood entity. It has been classified as either primary, resulting from trauma or musculoskeletal compression, or secondary to underlying cardiovascular or neoplastic disease.3Jones RH. Primary thrombosis of the axillary and subclavian veins.Ann Intern Med. 1951; 35: 454Crossref PubMed Scopus (2) Google Scholar, 4Kleinsasser LJ “Effort” thrombosis of the axillary and subclavian veins. An analysis of sixteen personal cases and fifty-six cases collected from literature.Arch Surg. 1949; 59: 258Crossref PubMed Scopus (46) Google Scholar, 5Adams JT DeWeese JA Mahoney EB Rob CG. Intermittent subclavian vein obstruction without trauma.Surgery. 1968; 63: 147Google Scholar, 6Campbell CB Chandler JG Tegtmeyer CJ Bernstein EF. Axillary, subclavian, and brachiocephalic vein obstruction.Surgery. 1977; 82: 6Google Scholar, 7Hashmonai M Schramek A Farbstein J. Cephalic vein crossover bypass for subclavian vein thrombosis: A case report.Surgery. 1976; 80: 563PubMed Google Scholar Numerous therapies have been proposed to help patients avoid recurrent debilitating symptoms. In most, early anticoagulation is effective. However, if sufficient recanalization or collateralization does not occur, the patient may need further treatment. The role for thrombectomy remains controversial in nonthreatened limbs; to enhance chances for success, it must be performed early before extensive thrombus organization occurs.8Jacobson JH Haimov M. Venous revascularization of the arm: Report of three cases.Surgery. 1977; 81: 599PubMed Google Scholar, 9Rabinowitz R Goldfarb D. Surgical treatment of axillosubclavian venous thrombosis: A case report.Surgery. 1971; 70: 703PubMed Google Scholar, 10Tilney NL Griffiths HJG Edwards EA. Natural history of major venous thrombosis of the upper extremity.Arch Surg. 1970; 101: 792Crossref PubMed Scopus (230) Google Scholar Other more complicated but successful autogenous vein bypass grafts have been reported. Witte and Smith11Witte LC Smith AC. Single anastomosis vein bypass for subclavian vein obstruction.Arch Surg. 1966; 93: 664Crossref PubMed Scopus (19) Google Scholar have utilized the internal jugular vein along with resection of the medial portion of the clavicle. Jacobson and Haimov8Jacobson JH Haimov M. Venous revascularization of the arm: Report of three cases.Surgery. 1977; 81: 599PubMed Google Scholar report two cases of bypass with the internal jugular vein, passed through subclavicular tunnels. Rabinowitz and Goldfarb9Rabinowitz R Goldfarb D. Surgical treatment of axillosubclavian venous thrombosis: A case report.Surgery. 1971; 70: 703PubMed Google Scholar used a saphenous vein graft interposed between the axillary and internal jugular vein. Hashmonai, Schramek, and Farbstein7Hashmonai M Schramek A Farbstein J. Cephalic vein crossover bypass for subclavian vein thrombosis: A case report.Surgery. 1976; 80: 563PubMed Google Scholar performed a cephalic vein crossover bypass. We have found no reports of external jugular vein bypasses over the clavicle, although this would appear to offer the simplest and least disfiguring approach. Several authors have reported decompression of the vein by resection of the first rib,8Jacobson JH Haimov M. Venous revascularization of the arm: Report of three cases.Surgery. 1977; 81: 599PubMed Google Scholar clavicle, anterior scalene, or subclavius muscles.12Daskalkis E Bouhoutsos J. Subclavian and axillary vein compression of musculoskeletal origin.Br J Surg. 1980; 67: 573Crossref PubMed Scopus (45) Google Scholar, 13McLeery RS Kesterson JE Kirtley JA Love RB. Subclavius and anterior scalene muscle compression as a cause of intermittent obstruction of the subclavian vein.Ann Surg. 1951; 133: 588Crossref PubMed Scopus (61) Google Scholar These approaches are based on the assumption that “effort” thrombosis is, in part, caused by anomalies of the thoracic outlet. Unquestionably this can be the case in some instances. However, in the absence of arterial or neurologic symptoms of thoracic outlet syndrome, simple vein bypass alone in this case was curative. In addition, some of these thoracic outlet procedures will be ineffective if the vein has an inadequate lumen. Claviculectomy is disfiguring as well. Venography to evaluate the character of the vein lumen and extent of obstruction is absolutely essential in planning an appropriate approach. Work in the field of venous bypass surgery has been plagued with early graft closure attributed to external compression, low luminal flow rates,14Bryant MF Lazenby WD Howard JM. Experimental replacement of short segments of veins.Arch Surg. 1958; 76: 289Crossref Scopus (32) Google Scholar and surgical technique. Arteriovenous fistulas have been introduced with venous reconstructive surgery to increase luminal flow, thus maintaining graft patency.14Bryant MF Lazenby WD Howard JM. Experimental replacement of short segments of veins.Arch Surg. 1958; 76: 289Crossref Scopus (32) Google Scholar, 15Schramek A Hashmonai M. Distal A-V fistula for the prevention of occlusion of venous interposition grafts to veins.J Cardiovasc Surg. 1974; 15: 392PubMed Google Scholar This is particularly simple to perform in the upper extremity and may be taken down at a later date when the anastomosis is healed and normal flow characteristics are established. Appropriate surgical technique is emerging as a very critical factor. Kinking of the vein must be avoided and magnification assures proper stitch placement. Pending results from future cases, a simple approach to subclavian vein thrombosis may emerge. In those instances without acute limb threat, anticoagulation with heparin and warfarin remains the treatment of initial choice unless, in the case of traumatic injury, it carries too high a risk of hemorrhage. Patients with late symptoms of venous hypertension and evidence of thoracic outlet syndrome may have either an outlet decompression or an outlet procedure plus a vein bypass if intraluminal obstruction exists. Patients having late symptoms of venous hypertension without other evidence of thoracic outlet syndrome might be best managed by jugular vein bypass over the clavicle.