Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa.
Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa.
J Vasc Surg Venous Lymphat Disord. 2019 Nov;7(6):839-844. doi: 10.1016/j.jvsv.2019.05.012. Epub 2019 Aug 27.
Traditional management of venous thoracic outlet syndrome (VTOS) has involved catheter-directed thrombolysis (CDT) followed by transaxillary or paraclavicular (PC) first rib resection. More recently, we have adopted an infraclavicular (IC) approach for first rib resection and five other strategies to treat these patients. We report our evolving experience with the treatment of acute VTOS.
We reviewed our prospectively maintained database to identify patients treated for VTOS. Our strategy includes CDT with pharmacomechanical thrombectomy, IC first rib resection during the same hospitalization, and subclavian vein angioplasty immediately after rib resection. Postoperatively, a sequential compression device was applied to the affected arm and low-dose heparin given through the ipsilateral venous sheath. Antiplatelet therapy was given for 6 weeks and anticoagulation for 6 months. Our strategy evolved from a PC to an IC approach, given that the added morbidity of the supraclavicular approach to allow excision of the posterior portion of the rib may add no benefit with VTOS compared with arterial or neurogenic thoracic outlet syndrome.
There were 51 patients who underwent first rib resection for VTOS, 11 (22%) through a PC approach and 40 (78%) through an IC approach. The average age was 36 years (range, 16-63 years), and the majority were female (36 [71%]) and involved the right subclavian vein (36 [71%]). All patients underwent preoperative CDT, 40 (78%) at our hospital and 11 (22%) elsewhere. Fifty patients (98%) underwent subclavian vein angioplasty after rib resection. A bare-metal stent was placed in two (4%) patients for persistent stenosis. Average length of stay was 3.7 (±2.1) days. Average operative time was 2.2 hours (range, 1.5-3.0 hours) when the IC approach was used vs 3.5 hours (range, 2.5-4.5 hours) for the PC approach (P < .0001). Of the entire group, one (2.6%) patient required reoperation for wound hematoma and six (12%) patients underwent repeated endovascular intervention for recurrent vein stenosis during follow-up (average, 38 months; range, 1-240 months). Primary and assisted primary patency rates at 3 years were 78% and 100%, respectively. There were no significant differences in patency rates or complications between the IC and PC approaches.
Our transition to an IC approach demonstrated low perioperative morbidity and excellent subclavian vein patency rates with shorter operative times compared with a PC approach. Our practice has evolved to include IC first rib resection followed by concomitant postoperative venous balloon angioplasty.
传统的静脉型胸廓出口综合征（VTOS）的治疗方法包括经导管溶栓（CDT），随后行腋窝或锁骨下旁（PC）第一肋骨切除术。最近，我们采用了锁骨下（IC）入路进行第一肋骨切除术，以及另外 5 种策略来治疗这些患者。我们报告了我们在治疗急性 VTOS 方面的不断发展的经验。
我们回顾了我们前瞻性维护的数据库，以确定接受 VTOS 治疗的患者。我们的策略包括 CDT 联合药物机械血栓切除术、同一住院期间行 IC 第一肋骨切除术，以及肋骨切除后立即行锁骨下静脉血管成形术。术后，将连续压缩装置应用于受影响的手臂，并通过同侧静脉鞘给予低剂量肝素。抗血小板治疗持续 6 周，抗凝治疗持续 6 个月。我们的策略从 PC 方法演变为 IC 方法，因为与动脉或神经性胸廓出口综合征相比，锁骨上方法增加的发病率以允许切除肋骨的后部分可能没有益处。
51 例患者因 VTOS 行第一肋骨切除术，其中 11 例（22%）经 PC 入路，40 例（78%）经 IC 入路。平均年龄为 36 岁（范围，16-63 岁），大多数为女性（36 [71%]），涉及右锁骨下静脉（36 [71%]）。所有患者均接受术前 CDT，其中 40 例（78%）在我院进行，11 例（22%）在其他地方进行。50 例（98%）患者在肋骨切除后行锁骨下静脉血管成形术。两名（4%）患者因持续性狭窄放置了裸金属支架。平均住院时间为 3.7（±2.1）天。当使用 IC 方法时，平均手术时间为 2.2 小时（范围，1.5-3.0 小时），而使用 PC 方法时为 3.5 小时（范围，2.5-4.5 小时）（P <.0001）。在整个组中，1 例（2.6%）患者因伤口血肿需要再次手术，6 例（12%）患者在随访期间因静脉再狭窄行重复血管内介入治疗（平均 38 个月；范围，1-240 个月）。3 年时的原发性和辅助原发性通畅率分别为 78%和 100%。IC 方法和 PC 方法之间的通畅率和并发症无显著差异。
与 PC 方法相比，我们向 IC 方法的转变显示出较低的围手术期发病率和出色的锁骨下静脉通畅率，并且手术时间更短。我们的实践已经发展到包括 IC 第一肋骨切除术，随后进行同时的术后静脉球囊血管成形术。
