Reoperations After Failed Transaxillary First Rib Resection for Subclavian Vein Thrombosis

With increasing frequency we are seeing patients who have undergone a late transaxillary approach to decompress the subclavian vein several weeks after the patient has been initially diagnosed and treated with thrombolytic agents and the thrombus has resolved. This policy is wrong. This tendency occurs despite the current recommendation to operate on these patients immediately at the time of the original event even if the vein has been reopened using either thrombolytics or percutaneous thrombectomy catheter [1, 2]. The longer the waiting period for a definitive surgery, the lesser the chance of reestablishing a long-term patency and flow in the subclavian vein (Fig. 22.1). After the radiologist clears the vein, many of these patients are operated using the transaxillary route to remove the first rib on the thesis that simply by decompressing the thoracic inlet, the subclavian vein normal function will be reestablished. This is not the case. Because of the limitation of the transaxillary approach to reach the actual site of extrinsic compression of the vein caused by the subclavian tendon and the costoclavicular ligament, plus added incomplete removal of the anterior end of the rib, (Fig. 22.2) these patients often re-thrombose or remain obstructed shortly after the thrombolytic stage is completed [3]. When these patients return with the same symptoms they are frequently subjected to prolonged periods of anticoagulation hoping to have the vein re-canalize. It never occurs. Patients may also then be subjected to balloon dilation of the obstructed segment, often accompanied by the placement of endovascular stents [4–8]. Most commonly this does not resolve the problem: the site of the extrinsic compression has not been relieved, and therefore the stent kinks and the vein reobstructs again (Fig. 23.1). Some of the patients that we have seen have undergone multiple balloon dilations and stent placements in the same area with no success (Fig. 23.2). The patients are often left with no hope of having a cure for this disabling condition. We highly recommended that if this is the situation, the patient must be reoperated using a different approach namely the anterior route [3]. This is the only way to access the site of extrinsic compression with which the vein is still affected, because the ligaments are still intact and the cartilaginous most anterior portion of the first rib has not been removed. Often enough, the vein also needs to be repaired directly using a vein patch as described in Chap. 12. Afterward, if needed a stent can also be implanted. Some of these examples are shown in Figs. 23.3a, b and 23.4a, b. Figure 23.5 depicts some of the initial intraoperative findings showing the still persistent mechanical obstruction of the subclavian vein at the inlet. The results of reoperating these patients have been rewarding. However, not every patient is a candidate for this operation, particularly if the elapsed time between the initial thrombosis to the time of the transaxillary operation resection has been long. In a series of 16 patients seen with persistent obstruction of the subclavian vein after transaxillary resection of the first rib we were able to repair appropriately only 11 (Table 23.1). In five of them the vein was already extensively damaged and the fibrotic process had extended into the axillary vein with no adequate lumen was available to attempt any type of reconstruction. It is strongly suggested therefore that if the patient undergoes a transaxillary resection of the first rib for Paget–Schroetter syndrome he/she should have an immediate postoperative venogram obtained to assess the status of the vein. If thrombosis persists, these patients should be reoperated using the anterior subclavicular route as soon as possible.