An algorithm for the management of primary subclavian vein thrombosis George Geroulakos National and Capodestrian University of Athens, Athens, Greece and Imperial College, London, UK

Congenital abnormal lateral insertion of the costoclavicular ligament and hypetrophy of the scalenous anterior in the Paget-Schroetter syndrome. (Urschel , 2008)

Upper extremity deep venous thrombosis (DVT) occurs in 1% to 4% of all DVTs

The first step in the management of acute subclavian vein thrombosis is restorations of luminal flow with thrombolysis. The timing and indications for surgery in patients with primary axillary/subclavian vein thrombosis are not well defined.

Thoracic outlet procedures may be associated with infrequent but significant morbidity such as injury to the brachial plexus causing paralysis (1%) or chronic pain syndromes, phrenic nerve injury (1%), subclavian artery/vein injury causing major bleeding(<1%) and chylothorax(<1%) .

Natural history studies 50 patients with primary effort thrombosis underwent thrombolysis and then were anticoagulated but did not undergo surgery. At 57 months 82% were entirely asymptomatic and 10% had mild symptoms. Illig, J.Vasc.Surg 2010

Outcome of thrombolysis with selective decompression in primary subclavian vein thrombosis 25 patients received thrombolytic treatment within a mean of 5.5 days. 12 patients had some degree of residual stenosis and had angioplasty after thrombolysis. At 2.9 years follow up only 2 patients underwent decompressive therapy and one is waiting for 1st rib resection. 6/21 patients were symptom free on DASH. 13/21 had mild symptoms. 2/21 patients severe symptoms. Lokanathan et al J.Vasc.Surg. 2001

Successful thrombolysis with positional stenosis/ occlusion with shoulder abduction Lee et al argued that the demonstration of a stenosis at the level of the costoclavicular junction and the loss of collateral flow during shoulder abduction does not suffice as the sole indication for surgery. 44% (n=4/9) of their, post thrombolysis ,conservatively treated patients had an obstruction of the collateral circulation on positional venography but remained asymptomatic and did not undergo surgery Lee, J.Vasc.Surg. 2000

Primary subclavian vein thrombosis and its long-term effect on quality of life Retrospective case control study on 45 consecutive patients Group 1 (n=14). Anticoagulation only Group 2 (n=14). Thrombolysis followed by anticoagulation Group 3 (n=17). Thrombolyis, 1st rib resection,anticoagulation Bosma et al, Vascular 2011

Primary subclavian vein thrombosis and its long-term effect on quality of life Patients in groups 2 and 3 had significantly less pain, swelling and fatigue in the afflicted limb at 6 weeks. There was no difference in pain (p=0,90), swelling (p=0.58), fatigue (p=0.61), functional impairment (p=0.61), recurrent of thrombosis (p=0.10) or QoL (p=0.25) between the groups at the end of FU (57 months) Bosma et al; Vascular 2011

Patients can generally be classified in 4 groups as shown on the completion venography of the sublavian vein: 1. Successful thrombolysis no residual stenosis 2. Unsuccessful thrombolysis 3. Successful thrombolysis with positional stenosis/ occlusion with shoulder abduction. 4. Incomplete thrombolysis with intrinsic stenosis

Successful thrombolysis no residual stenosis Many surgeons would not perform first rib resection if positional venography shows no stenosis/occlusion of the subclavian vein. In these cases the presence of thrombophilia should be investigated. The patients should be treated for 3 months with anticoagulation and should be re-evaluated if recurrent symptoms occur.

Successful thrombolysis with positional stenosis/ occlusion with shoulder abduction Asymptomatic or minimally symptomatic patients should be anticoagulated for 3 months and then should be followed up and only considered for surgery if the symptoms deteriorate or in case of rethrombosis . Patients with moderate or severe symptoms should be considered for 1st rib resection.

Unsuccessful thrombolysis in primary subclavian venous thrombosis If the vein has not recanalised, decompression of the thoracic outlet should not be considered. The patient should continue on anticoagulation for several months and the symptoms should be re-evaluated. If symptoms are significant the patient with a short occlusion (aprox 2cm) may be considered for an internal jugular to subclavian vein bypass. Sanders, 1991

Conclusions Thoracic outlet decompression is not without the potential of serious complications such as brachial pulsy, chronic post operative pain syndromes and phrenic nerve pulsy. In almost all series the effect of surgery was subjectively assessed without the use of disease specific quality of life questionnaires.

Conclusions There are no randomised studies or large series addressing the indications and appropriate timing of first rib resection following thrombolysis for thoracic outlet syndrome. An aggressive surgical approach seems to be justified only for patients with persistent symptoms post thrombolysis. Rethrombosis should be treated with thrombolysis and first rib resection on the same admission.

ACUTE SUBCLAVIAN VEIN THROMBOSIS Thrombolysis No residual stenosis Unsuccessful thrombolysis Partial stenosis/occlusion Minimal symptoms Moderate/severe symptoms Conservative Conservative Re-thrombosis Severe symptoms Thrombolysis JUGULAR-AXILLARY BYPASS ? FIRST RIB RESECTION