Peripheral Vascular Surgery Society
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Peripheral Vascular Surgery Society |
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#15 TREATMENT OF RESIDUAL SUBCLAVIAN VEIN STENOSIS FOLLOWING THROMBOLYSIS, FIRST RIB RESECTION AND VENOLYSIS FOR EFFORT THROMBOSIS: CASE REPORTS AND REVIEW OF THE LITERATURE
Eric S. Weinstein, MD, Michael A. Cooper, MD, Richard A. Sanders, MD, Sharon DL. Hammond, MD, and Glenn L. Kelly, MD
Swedish Medical Center Englewood, CO
Optimal therapy for residual subclavian vein stenosis (RSVS) following successful thrombolytic therapy, first rib resection and venolysis for effort thrombosis has yet to be determined. Treatment options include anticoagulation, balloon angioplasty/stent, direct subclavian vein repair, or autogenous bypass.
We present the following three cases of RSVS following first rib resection and venolysis for effort thrombosis which exemplify the complexity of the problem.
Case 1 is a 53 year old retired policeman who's left subclavian effort thrombosis was treated with a transaxillary first rib resection and extensive subclavian venolysis following successful lytic therapy. The degree of RSVS following venolysis was not fully appreciated by palpation intraoperatively, but was well demonstrated by postoperative venography obtained on POD #1. Balloon angioplasty performed at that time was complicated by rupture of the subclavian vein, requiring emergent repair via an infraclavicular approach. The patient subsequently did well after a stormy postoperative course.
Case 2 is an 18 year old male weight lifter who developed left arm swelling and pain after a vigorous workout. Successful thrombolytic therapy was followed in 24 hours by infraclavicular first rib resection and venolysis. Intraoperative venography demonstrated significant RSVS which was treated with endovenectomy and vein patch angioplasty. Post completion venography demonstrated a widely patent subclavian vein and the patient's symptoms resolved after 48 hours.
Case 3 is a 29 year old male who underwent thoracic outlet decompression 9 years prior to re-presenting with ipsilateral arm swelling and pain. Diagnostic venography demonstrated a subclavian vein occlusion and the patient underwent successful reconstruction with a jugular vein turndown procedure.
A detailed description of the operative approaches utilized in all three cases is provided along with a review of the medical literature. The importance of post venolysis venography is stressed and an algorithm for treatment is proposed.
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Last updated January 10, 1999