- 1.Decompression: At minimum, relieving the arterial compression involves resection of cervical or first ribs, fibrous bands, scalenectomy, and removing any other associated anomalies. Some authors suggest that the first rib should be routinely removed to prevent recurrence of symptoms because it acts as a key insertion point for fibromuscular bands that cause vascular compression.13Others argue that anterior and middle scalenectomy alone is as effective as scalenectomy with first rib resection, and that a rib-sparing approach leads to less morbidity, including a lower risk of pleural or plexus injury and shorter hospital stay.14,15However, the evidence for this is limited, and largely focused on patients with a past history of neurogenic TOS. Consequently, for now, one approach cannot be recommended over another.
- 2.Arterial resection: Resection of any potential source of arterial embolus such as a subclavian artery aneurysm or luminal stenosis with intimal damage is necessary to prevent ischemic complications of the upper extremity.
- 3.Distal revascularization: Vascular reconstruction in the form of primary anastomosis, interposition graft, or axillary-brachial bypass may be required depending on the extent of the subclavian artery resection. If evidence of distal embolus is present, intraarterial thrombolysis or thromboembolectomy may be used in conjunction with arterial reconstruction to improve outflow of the limb.
- Skalicka L.
- Lubanda J.-C.
- Jirat S.
- et al.
- 1.Acute: For patients presenting acutely (<6 weeks since symptom onset), prompt catheter-directed thrombolysis with early surgical decompression of the thoracic outlet has been reported to produce >90% clinical success. A short course of anticoagulation may be required until venous patency is confirmed by postoperative imaging. Venoplasty of a residual subclavian vein stenosis after decompression may be considered to reduce the risk of rethrombosis.
- 2.Chronic: Patients presenting with chronic (≥6 weeks) stenosis or occlusion of the subclavian vein with evidence of vTOS benefit from surgical decompression. Preoperative thrombolysis may be considered in patients with total occlusion in an attempt to restore luminal patency before decompression. A course of postoperative anticoagulation may be required until venous patency is confirmed by postoperative imaging. Venoplasty of a residual subclavian vein stenosis may be considered to reduce the risk of rethrombosis.
- 3.Intermittent obstruction: Patients with chronic symptoms of intermittent venous obstruction but without evidence of thrombus or significant stenosis require only surgical decompression. Thrombolysis, anticoagulation, or venoplasty are generally not required.
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