Long-Term Results of Local Thrombolysis Followed by First Rib Resection: An Encouraging Clinical Experience in Treatment of Subclavian Vein Thrombosis

Abstract

The purpose of this study was to present the long-term results of our experience, which includes thrombolysis, surgical decompression, and long-term anticoagulation. The medical records of 24 patients who were admitted to Academic Hospital Vrije Universiteit, Amsterdam, the Netherlands, between January 1983 and October 1997, with effort thrombosis of the subclavian vein were reviewed. There were 21 men and 3 women, with a mean age of 30.5 years and an average duration of the symptoms of 2.9 days. Clinical diagnosis was confirmed by phlebography and duplex in all patients. A loading dose of 10,000 units streptokinase was given followed by an infusion at a rate of 10,000 units per hour. Phlebography was repeated daily in order to evaluate the effect of the treatment. Thrombolysis was achieved in 2 to 8 days (mean 5 days). After achievement of complete thrombolysis, anticoagulation with heparin and coumarin derivatives was started; the latter were continued for 3 months.

Six to 12 weeks after the thrombolysis, patients with costoclavicular compression syndrome underwent surgery. A transaxillary first rib resection, partial scalenotomy, and transection of the tendon of subclavian muscle were performed. Thrombolysis was achieved in all patients but one, with a successful lysis percentage of 95.8%. In one patient, the local streptokinase therapy had to be discontinued because of pulmonary embolism. Resection of the first rib was performed on 19 patients. Two patients refused to be operated on. The other three were lost to follow-up, right after the thrombolytic therapy. In long-term evaluation, all the patients who underwent first rib resection were symptom free, whereas the two patients who refused to be operated on had pain and discoloration of the affected arm, although venous patency was achieved.

The subclavian vein thrombosis occurs as a result of repetitive trauma due to anatomic constriction of the vein by the clavicle and the first rib complex. Therefore, we advise addressing the therapy not only to the superimposed thrombus but also to the correction of the underlying anatomic abnormality.

References

1. Rauwerda JA , Bakker FC , van den Broek TAA , et al: Spontaneous subclavian vein thrombosis: A successful combined approach of local thrombolytic therapy followed by first rib resection. Surgery 4:477-480, 1988.

2. Harley DP , White RA , Nelson RJ , et al: Pulmonary embolism secondary to venous thrombosis of the arm. Am J Surg 147:221-224, 1984.

3. Coon WW , Willis PW : Thrombosis of axillary and subclavian vein. Arch Surg 94:657-663, 1967.

4. Kleinsasser LJ : Effort thrombosis of the axillary and subclavian vein. Arch Surg 59:258-274, 1949.

5. Smith BM , Shield GW , Riddel DH , et al: Venous gangrene of the upper extremity. Ann Surg 201:511-519, 1985.

6. Haimovici H : Gangrene of the extremities of the venous origin. Review of the literature with case reports. Circulation 1:225-240, 1950.

7. Haimovici H : The ischemic forms of the venous thrombosis: 1. Plegmasia cerulea dolens. 2. Venous gangrene. J Cardiovasc Surg 5-18(suppl):164-173, 1965.

8. Donayre CE , White GN , Mehringer SM , et al: Pathogenesis determines late morbidity of axillosubclavian thrombosis. Am J Surg 152:179-184, 1986.

9. Taylor LM , McAllister WR , Dennis DL , et al: Thrombolytic therapy followed by first rib resection for spontaneous “effort” subclavian vein thrombosis. Am J Surg 149:644-647, 1985.

10.

10. Aziz S , Straehley CJ , Whelan TJ : Effort-related axillosubclavian vein thrombosis. Am J Surg 152:57-61, 1986.

11.

11. Jamieson CW : Venous complication of thoracic outlet syndrome. Eur J Vasc Surg 1:1-3, 1987.

12.

12. Swinton NW , Edgett JW , Hall RJ : Primary subclavian-axillary vein thrombosis. Circulation 38:737-745, 1968.

13.

13. Tilney NL , Griffiths HJG , Edwards EA : Natural history of major venous thrombosis of the upper extremity. Arch Surg 101:792-796, 1970.

14.

14. Molina JE : Surgery for effort thrombosis of the subclavian vein. J Thorac Cardiovasc Surg 103:341-345, 1992.

15.

15. Landercasper JE , Gall W , Fischer M , et al: Thrombolytic therapy for axillary-subclavian venous thrombosis. Arch Surg 122:1072-1075, 1987.

16.

16. Pittam MR , Darke SG : The place of the first rib resection in the management of axillary-subclavian vein thrombosis. Eur J Vasc Surg 1:5-10, 1987.

17.

17. Prescott SM , Tikoff G : Deep venous thrombosis of the upper extremity: A reappraisal. Circulation 59:350-355, 1979.

18.

18. Druy EM , Trout HH III , Giordana JM , et al: Lytic therapy in the treatment of axillary and subclavian vein thrombosis. J Vasc Surg 2:821-827, 1985.

19.

19. Wilson JJ , Lesk D , Newman H : Subclavian-axillary vein thrombosis: A successful treatment with streptokinase. Can Med Assoc J 130:891-893, 1984.

20.

20. Becker GJ , Holden RW , Rabe FE , et al: Local thrombolytic therapy for subclavian and axillary vein thrombosis. Radiology 149:419-423, 1983.

21.

21. Hess H : Thrombolytic therapy in peripheral vascular disease. Br J Surg 77:1083-1084, 1990.

22.

22. Adams JT , De Weese JA : “Effort” thrombosis of the axillary and subclavian veins. J Trauma 11:923-930, 1971.

23.

23. Warden GD , Wifore DW , Pruitt BA : Central venous thrombosis: A hazard of medical progress. J Trauma 13:620-626, 1973.

24.

24. Arnesen H , Heilo A , Jacobsen E : A prospective study of streptokinase and heparin in treatment of deep vein thrombosis. Acta Med Scand 203:457-463, 1978.

25.

25. Tsapogas JM , Peabody RA , Wu KT , et al: Controlled study of thrombolytic therapy in deep vein thrombosis. Surgery 74:973-984, 1973.

26.

26. Belkin M , Belkin B , Bucknam-CA , et al: Intraarterial fibrinolytic therapy. Arch Surg 121:769-773, 1986.