eMedicine Specialties > Radiology > Vascular/Interventional

Thoracic Outlet Syndrome: Follow-up

Author: Meghal Antani, MD, Consulting Staff, Department of Interventional Radiology, Washington Hospital Center
Coauthor(s): Gary P Siskin, MD, Associate Professor, Department of Radiology, Albany Medical College; Chief, Division of Vascular and Interventional Radiology, Department of Radiology, Albany Medical Center
Contributor Information and Disclosures

Updated: Jun 10, 2008

Intervention

Arterial procedures

In a patient presenting with acute symptoms of arterial thoracic outlet syndrome with associated severe ischemia of the extremity, emergency surgery is the preferred treatment to restore circulation; however, if extensive distal thrombosis or embolization is present, transcatheter thrombolysis of the occluded runoff or emboli should be considered prior to surgical repair of the causative central lesion.

Goals of surgery include the following:

• Restoration perfusion to the distal extremity (eg, with thromboembolectomy)
• Repair of the anatomic anomaly causing the narrowing of the thoracic outlet (which commonly involves excision of the first rib and other abnormal bone and soft tissue)
• Reconstruction of the arterial segment in the thoracic outlet, which is often the source of the emboli

Surgical results for arterial complications are most favorable with prompt diagnosis and treatment and prior to the onset of irreversible ischemia. In a review of 137 patients by Sanders and Haug, 84% of patients had successful results after surgical treatment for arterial thoracic outlet syndrome.²³

Percutaneous transluminal angioplasty has recently gained favor, especially for patients who are poor surgical candidates or have mild arm claudication or weakness. Several groups have investigated the long-term results of angioplasty for the treatment of obstruction or stenosis in the subclavian arteries. Farina et al compared the outcomes in 21 patients undergoing proximal subclavian angioplasty with the outcomes in 15 patients undergoing surgical carotid-subclavian reconstruction. Patency rates for angioplasty progressively decreased from an initial rate of 91% to 54% at 5 years, but the rates for surgical reconstruction remained unchanged at approximately 86%.²⁴

A review by Hebrang et al of 45 patients undergoing subclavian angioplasty demonstrated normal blood pressure findings in the treated arm in 91% of patients, with a mean follow-up of 29 months.²⁵ A review by Wilms et al revealed continued relief of symptoms after 25 months in 86% of 21 patients.²⁶ Körner reported a secondary cumulative patency rate of 72% after a 100-month follow-up in 28 patients who underwent subclavian and innominate angioplasty.²⁷

Thrombolysis is a potential treatment option that can be considered immediately after a diagnostic angiogram reveals subclavian or axillary occlusion. As part of a larger review of the vascular causes of thoracic outlet syndrome, Hood et al reported the results in 3 patients with acute upper extremity emboli. Two of these patients received thrombolytic therapy and were without symptoms after 22-month follow-up.²⁸

Debate continues about the role of angioplasty and thrombolysis versus that of surgery in a patient with acute symptoms of arterial thoracic outlet syndrome. If angioplasty is performed, careful follow-up is important, and Doppler sonography should be performed on a regular basis to evaluate for the recurrence of stenosis.²⁹

Venous procedures

Prognosis and treatment differ for the 2 types of venous thoracic outlet syndrome.

Patients with primary venous thrombosis more commonly present with acute symptoms, including arm swelling and pain, which often limit their activity. Anticoagulant therapy reduces the extension of thrombus as well as the associated (minute) risk of pulmonary embolism; however, multiple authors have demonstrated minimal long-term benefits of anticoagulation.

Intervention is often performed early for rapid symptomatic relief, especially in an otherwise healthy patient who requires full use of the affected arm. Catheter-directed thrombolysis and mechanical thrombectomy have significantly expanded the nonsurgical options for treatment. With surgical thoracic outlet decompression, the success rate has averaged 81%. Other advantages to catheter-directed thrombolysis include the ability to perform diagnostic venograms at the time of thrombolysis in various positions to provoke the symptoms and the ability to perform postthrombolysis venograms to document the extent of residual thrombus.

The disadvantages of thrombolysis include the risk of bleeding, which can be minimized by following prescribed dosing guidelines. Another concern is the fact that the underlying thoracic outlet compression is not addressed; therefore, a surgical procedure may still be needed later. Thrombolysis is most effective if performed within 7-10 days; at least 2 studies have shown a significant decrease in the effectiveness of thrombolysis after 10 days.

The timing of thoracic outlet decompressive surgery after thrombolysis has been a source of considerable debate in the literature. The most common approach involves a waiting period of approximately 3 weeks, during which the patient received oral anticoagulation and the vascular endothelium is allowed to heal. Then, decompressive surgery is performed if a postthrombolysis venogram shows focal extrinsic compression. If extrinsic compression resulting from an anatomic cause is not noted on the follow-up venogram, the need for surgical intervention is less clear.

In a survey by Rutherford and Hurlbert, 86% of vascular surgeons surveyed opted for a conservative approach in this scenario, with anticoagulation therapy administered for 3-6 months, during which the patient is observed for evidence of recurrent thrombosis. If the postthrombolysis venogram reveals an intrinsic stenosis with or without extrinsic compression, percutaneous venoplasty augmented by stent placement becomes an option, although the precise role of venoplasty and stent use remains an area of considerable disagreement.³⁰

Most authors do not recommend stent placement without surgical decompression because the stent itself may be compressed or become fragmented by the thoracic outlet narrowing. Dowling et al reported a case of venous thoracic outlet syndrome treated with thrombolysis, angioplasty, and stent placement without immediate first-rib resection. The case was later complicated by stent fracture.³¹ Meier et al reported a series of 6 patients who underwent venous stent placements immediately after thrombolysis for venous thoracic outlet syndrome and 2 patients who underwent delayed stent procedures. Two of the 6 patients who underwent immediate stent placement did not undergo immediate surgical rib resection, and both patients had the complication of stent fracture. Long-term (1-3 y) patency was achieved in 6 of the 8 patients.³²

The timing of the intervention continues to be debated. Some authors recommend a phase of venous intimal healing after thrombolysis and before venoplasty or stent placement to reduce further damage to the vessel resulting in recurrent thrombosis. Other authors have proposed the use of venoplasty only after surgical resection of the first rib, when the source of the thoracic outlet compression has been removed. Molina has proposed that thrombolysis be performed first, followed by emergency surgery, for the highest likelihood of avoiding recurrent strictures and chronic symptoms.³³

Kreienberg et al reported their outcomes that support early surgical and radiologic intervention. Twenty-three patients with venous thoracic outlet syndrome were treated with thrombolysis, followed by immediate (within 24 hours) surgical thoracic inlet decompression (including rib resection and removal of the anterior scalene muscle) and then angioplasty within 24 hours. Stents were placed to treat residual venous stenosis (>50%) in 14 patients. Of the veins treated with only angioplasty, all were patent at a mean follow-up of 4 years. Of those additionally treated with stent placement, 9 were patent at a mean follow-up of 3.5 years. No stent fractures were observed. Occluded stents were associated with longer stenoses and hypercoagulable states. From these findings, Kreienberg et al concluded that early surgical intervention followed by early radiologic intervention is safe and effective and that subclavian venous stent use is effective in short venous stenoses.³⁴

If the postthrombolysis venogram demonstrates inadequate thrombolysis or residual obstruction, most vascular surgeons favor discontinuation of thrombolysis and initiation of a conservative treatment approach with anticoagulation, elevation, and support of the arm. According to Rutherford and Hurlbert, only one third of surgeons favor an attempt at venoplasty with or without stent placement (see Images 5-6) and only 15% favor surgical decompression. If the patient remains symptomatic with residual stenosis, 80% of vascular surgeons favor surgical intervention with short stenosis (66% favoring jugular vein turndown, 14% favoring claviculectomy) and 48% favor a bypass (either saphenous vein interposition or cephalic vein crossover) with long stenosis. These findings reflect the overall success of surgical intervention.³⁰

Secondary venous thrombosis, often associated with central venous catheters, usually occurs with an insidious onset and minimal symptoms if any. Anticoagulation with heparin, followed with the long-term administration of warfarin, is the preferred treatment. In uncomplicated cases, thrombolysis has not had a definite benefit, and it does have significant associated complications. In patients with a definite contraindication to anticoagulation, McCarthy et al reported success with simple conservative measures such as arm elevation and compressive dressings, and they propose reserving invasive therapies, such as thrombolysis, surgical thrombectomy, and rib resection, for patients with severe symptoms not responsive to anticoagulation. Interventional therapies, such as angioplasty and thrombolysis, are often more difficult to perform in secondary venous thrombosis because these cases are more likely to be chronic.^{33,35,36,37,38,39,40,41,42,43,44}

Medicolegal Pitfalls

• Although stents are useful in those patients in whom angioplasty alone fails, endovascular stent deployment for some of these vascular stenoses is not specifically approved by the US Food and Drug Administration (FDA), although stents are used on a case-by-case off-label basis.
• An article in the American Journal of Roentgenology described a malpractice lawsuit brought against an interventional radiologist for negligence in using venous stents in a manner not approved by the FDA. This case highlights the importance of obtaining written informed consent.⁴⁵

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