Long-term results of local thrombolysis followed by first rib resection: An encouraging clinical experience in treatment of subclavian vein thrombosis

The purpose of this study was to present the long-term results of our exper ience, which includes thrombolysis, surgical decompression, and long-term a nticoagulation. The medical records of 24 patients who were admitted to Aca demic Hospital Vrije Universiteit, Amsterdam, the Netherlands, between Janu ary 1983 and October 1997, with effort thrombosis of the subclavian vein we re reviewed. There were 21 men and 3 women, with a mean age of 30.5 years a nd 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 10,0 00 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 hep arin and coumarin derivatives was started; the latter were continued for 3 months. Six to 12 weeks after the thrombolysis, patients with costoclavicular compr ession syndrome underwent surgery. A transaxillary first rib resection, par tial scalenotomy, and transection of the tendon of subclavian muscle were p erformed. Thrombolysis was achieved in all patients but one, with a success ful lysis percentage of 95.8%. In one patient, the local streptokinase ther apy 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 t herapy. In long-term evaluation, all the patients who underwent first rib r esection were symptom free, whereas the two patients who refused to be oper ated on had pain and discoloration of the affected arm, although venous pat ency 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 comp lex. Therefore, we advise addressing the therapy not only to the superimpos ed thrombus but also to the correction of the underlying anatomic abnormali ty.