Surgical intervention is not required for all patients with subclavian vein thrombosis

Purpose: The role of thoracic outlet decompression in the treatment of prim ary axillary-subclavian vein thrombosis remains controversial. The timing a nd indications for surgery are not well defined, and thoracic outlet proced ures may be associated with infrequent, but significant, morbidity. We exam ined the outcomes of patients treated with or without surgery after the res ults of initial thrombolytic therapy and a short period of outpatient antic oagulation. Methods: Patients suspected of having a primary deep venous thrombosis unde rwent an urgent color-flow venous duplex ultrasound scan, followed by a ven ogram and catheter-directed thrombolysis. They were then converted from hep arin to outpatient warfarin. Patients who remained asymptomatic received an ticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptom s of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent th oracic outlet decompression and postoperative anticoagulation for 1 month. Results: Twenty-two patients were treated between June 1996 and Tune 1999. Of the 18 patients who received catheter-directed thrombolysis, complete pa tency was achieved in eight patients (44%), and partial patency was achieve d in the remaining 10 patients (56%). Nine of 22 patients (41%) did not req uire surgery and the remaining 13 patients underwent thoracic outlet decomp ression through a supraclavicular approach with scalenectomy, first-rib res ection, and venolysis. Recurrent thrombosis developed in only one patient d uring the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surge ry sustained durable relief of their symptoms and a return to their baselin e level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging. Conclusion: Not all patients with primary axillary-subclavian vein thrombos is require surgical intervention. A period of observation while patients ar e receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persi stent symptoms and venous obstruction should be offered thoracic outlet dec ompression. Chronic anticoagulation is not required in these patients.