Infraclavicular first rib resection for the treatment of acute venous thoracic outlet syndrome.

OBJECTIVE: Venous thoracic outlet syndrome (VTOS) is most commonly treated by transaxillary, supraclavicular, or paraclavicular approaches, based on surgeon preference. However, we have adopted an infraclavicular approach to VTOS as the surgical pathology is in the anterior costoclavicular space. We hypothesize that this approach, combined with catheter-directed thrombolysis (CDT) with venoplasty as needed, provides safe and effective treatment of patients with an acute presentation of VTOS.

METHODS: We retrospectively reviewed all consecutive patients that underwent infraclavicular thoracic outlet decompression for an acute presentation of VTOS from July 2005 to February 2014 by a single surgeon. Acute presentation was defined as less than 14 days between the onset of symptoms and CDT. Demographics, primary and secondary subclavian vein patency, perioperative outcomes, and reinterventions were recorded.

RESULTS: There were 33 patients that underwent an infraclavicular approach for treatment of VTOS. Average age was 35 years, and 61% were male. All patients underwent CDT, subsequent infraclavicular first rib resection, and intraoperative venography. Intraoperative subclavian vein angioplasty was performed in 70%. Median postoperative length of stay was 2 days (range, 2-6 days), blood loss was 78 mL (range, 20-200 mL), and operative time was 120 minutes (range, 76-166 minutes). Median follow-up was 78 days (range, 2-483 days). Follow-up ultrasound showed all patients having a patent subclavian vein at last follow-up. Reinterventions included two cases for rethrombosis and one case of hemothorax. Primary patency was 91%, and secondary patency was 100%. There were no complications of brachial plexus or phrenic nerve injury. All patients at last follow-up were symptom-free, and subclavian veins were patent.

CONCLUSIONS: An infraclavicular approach is a safe and effective treatment for acute VTOS. It provides excellent access to the costoclavicular space for first rib resection and subclavian venolysis while at the same time minimizing the risk of brachial plexus and phrenic nerve injury.