Anthony Azakie, MD, Doff B. McElhinney, MD, Robert W

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Presentation transcript:

Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression Anthony Azakie, MD, Doff B. McElhinney, MD, Robert W. Thompson, MD, Raymond B. Raven, MD, Louis M. Messina, MD, Ronald J. Stoney, MD Journal of Vascular Surgery Volume 28, Issue 5, Pages 777-786 (November 1998) DOI: 10.1016/S0741-5214(98)70052-7 Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 1 A, Normal anatomy of costoclavicular region during upper extremity adduction, B, with oblique parasagittal cross-section through normal costoclavicular space at the level of anterior scalene muscle. Subclavian vein passes between clavicle and subclavius muscle anterosuperiorly, first rib inferiorly, and anterior scalene muscle posteriorly. Subclavius muscle runs anterior to subclavian vein and inserts medially on head of first rib. In adduction, subclavian vein is not compressed. C, Normal anatomy of costoclavicular region during upper extremity abduction, D, with oblique parasagittal cross-section through costoclavicular space, as described above. Anterior scalene muscle is contracted, pulling first rib superiorly. Subclavius muscle also is contracted. As a result, costoclavicular space is narrowed. m, Muscle; v, vein. Journal of Vascular Surgery 1998 28, 777-786DOI: (10.1016/S0741-5214(98)70052-7) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 Cross-sections through costoclavicular space during abduction, as described in Fig 1. A, Patient with acute subclavian-vein thrombosis after thrombolytic recanalization. Costoclavicular space is narrowed abnormally, and subclavian vein undergoes compressive occlusion. There is perivenous fibrosis and inflammation of vein wall. This recapitulates prethrombotic state. B, Patient with chronic subclavian-vein occlusion. Prominent first-rib bypass graft collaterals are compressed on abduction. C, After transaxillary first-rib resection, there is unresected medial portion of first rib, which, during abduction, contributes to subclavian-vein compression, perivenous adventitial inflammation and fibrosis, and risk of subsequent thrombosis. D, After supraclavicular resection of anterior scalene, subclavius, and entire first rib with circumferential venolysis, costoclavicular space is effectively decompressed. m, Muscle; v, vein. Journal of Vascular Surgery 1998 28, 777-786DOI: (10.1016/S0741-5214(98)70052-7) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 4 A, Preoperative acute thrombosis of right subclavian vein followed by recanalization. On abduction, there is positional compression of subclavian vein. B and C, After operative decompression, subclavian vein is widely patent on adduction and shows improvement on abduction relative to preoperative state. Journal of Vascular Surgery 1998 28, 777-786DOI: (10.1016/S0741-5214(98)70052-7) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 5 A, This is left subclavian vein during positional venography in a patient with acute subclavian-vein thrombosis. Subclavian vein is compressed and completely occluded. B, After costoclavicular decompression for acute thrombosis, with first-rib resection, scalenectomy, and circumferential venolysis via the supraclavicular approach, there is residual stenosis as a result of stricture. C, Balloon venoplasty in decompressed costoclavicular space yields resolution of residual stricture. Journal of Vascular Surgery 1998 28, 777-786DOI: (10.1016/S0741-5214(98)70052-7) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 3 Preoperative venogram in patient with acute thrombosis recanalized with lytic therapy. Subclavian-vein stenosis here was treated with percutaneous balloon angioplasty and stent placement. Note kinking of stent between clavicle and first rib, and note mural thrombus formation. Journal of Vascular Surgery 1998 28, 777-786DOI: (10.1016/S0741-5214(98)70052-7) Copyright © 1998 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions