Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients

A surgical method to be reminded for the treatment of symptomatic ipsilateral central venous occlusions in patients with hemodialysis access: Axillo-axillary venous bypass case report and review of the literature

BACKGROUND

In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature.

METHODS

The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema.

RESULTS

Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery.

CONCLUSION

In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.

Options for Dialysis and Vascular Access Creation

End-stage kidney disease (ESKD) affects nearly 800,000 patients in the United States. The choice of peritoneal dialysis (PD) versus hemodialysis (HD) should be patient centric. An ESKD Life-Plan is crucial with the goal of creating the right access, for the right patient, at the right time, for the right reason. Complex access should be considered when straightforward access options have been exhausted. Evolving techniques such as percutaneous access for HD and PD should be further investigated. Shared decision-making and palliative care is an essential part of the care of patients with CKD and ESKD..

Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome)

OBJECTIVE

We assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS).

METHODS

We performed a retrospective, single-center review of 266 patients who had undergone primary surgical treatment of VTOS between 2016 and 2022. The clinical outcomes were compared between the patients in four treatment groups determined by intraoperative venography.

RESULTS

Of the 266 patients, 132 were male and 134 were female. All patients had a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range, 12-66 years). The timing of clinical presentation was acute (<15 days) for 132 patients (50%), subacute (15-90 days) for 71 (27%), and chronic (>90 days) for 63 patients (24%). Venography with catheter-directed thrombolysis or thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 patients (71%). The median interval between symptom onset and surgery was 78 days. After paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%). However, 26 (10%) had a long chronic AxSCV occlusion with axillary vein inflow insufficient for bypass reconstruction. Patch angioplasty was performed for focal AxSCV stenosis in 55 patients (21%) and bypass graft reconstruction for segmental AxSCV occlusion in 35 (13%). The patients who underwent external venolysis alone (patent or occluded AxSCV; n = 176) had a shorter mean operative time, shorter postoperative length of stay and fewer reoperations and late reinterventions compared with those who underwent AxSCV reconstruction (patch or bypass; n = 90), with no differences in the incidence of overall complications or 30-day readmissions. At a median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling, and only 17 (6%) were receiving anticoagulation treatment; 95% of those with a patent AxSCV at the end of surgery were free of arm swelling vs 69% of those with a long chronic AxSCV occlusion (P < .001). The patients who had undergone CDT at the initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery (30% vs 44%; P = .034) and 60% less likely to have arm swelling at follow-up (5% vs 13%; P < .05) vs those who had not undergone CDT.

CONCLUSIONS

Paraclavicular decompression, external venolysis, and selective AxSCV reconstruction determined by intraoperative venography findings can provide successful and durable treatment for >90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt usage of CDT, and even more effective surgical treatment.

Venous thoracic outlet syndrome and hemodialysis

Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.

Thoracic Outlet Syndrome: Fingertip Cannot Replace Forearm Photoplethysmography in the Evaluation of Positional Venous Outflow Impairments

Objective: Fingertip photoplethysmography (PPG) resulting from high-pass filtered raw PPG signal is often used to record arterial pulse changes in patients with suspected thoracic outlet syndrome (TOS). Results from venous (low-pass filtered raw signal) forearm PPG (V-PPG) during the Candlestick-Prayer (Ca + Pra) maneuver were recently classified into four different patterns in patients with suspected TOS, two of which are suggestive of the presence of outflow impairment. We aimed to test the effect of probe position (fingertip vs. forearm) and of red (R) vs. infrared (IR) light wavelength on V-PPG classification and compared pattern classifications with the results of ultrasound (US).

Methods: In patients with suspected TOS, we routinely performed US imaging (US + being the presence of a positional compression) and Ca + Pra tests with forearm V-PPG_IR. We recruited patients for a Ca + Pra maneuver with the simultaneous fingertip and forearm V-PPG_R. The correlation of each V-PPG recording to each of the published pattern profiles was calculated. Each record was classified according to the patterns for which the coefficient of correlation was the highest. Cohen’s kappa test was used to determine the reliability of classification among forearm V-PPG_IR, fingertip V-PPG_R, and forearm V-PPG_R.

Results: We obtained 40 measurements from 20 patients (40.2 ± 11.3 years old, 11 males). We found 13 limbs with US + results, while V-PPG suggested the presence of venous outflow impairment in 27 and 20 limbs with forearm V-PPG_IR and forearm V-PPG_R, respectively. Fingertip V-PPG_R provided no patterns suggesting outflow impairment.

Conclusion: We found more V-PPG patterns suggesting venous outflow impairment than US + results. Probe position is essential if aiming to perform upper-limb V-PPG during the Ca + Pra maneuver in patients with suspected TOS. V-PPG during the Ca + Pra maneuver is of low cost and easy and provides reliable, recordable, and objective evidence of forearm swelling. It should be performed on the forearm (close to the elbow) with either PPG_R or PPG_IR but not at the fingertip level.

Invited Review: Optimal Management of Upper Extremity DVT: Is Venous Thoracic Outlet Syndrome Underrecognized?

BACKGROUND

UEDVT accounts for approximately 10% of all cases of deep vein thrombosis. In the most widely referenced general review of deep vein thrombosis (DVT the American Academy of Chest Physicians essentially recommend that upper extremity DVT (UEDVT) essentially be treated identically to that of lower extremity DVT, with anticoagulation being the default therapy. Unfortunately, the medical literature does not well differentiate between DVT in the arm and the leg, and does not emphasize the effects of the costoclavicular junction (CCJ) and the lack of effect of gravity, to the point where UEDVT due to extrinsic bony compression at the CCJ is classified as "primary."

METHODS

Comprehensive literature review, beginning with both Medline and Google Scholar searches in addition to collected references, then following relevant citations within the initial manuscripts studied. Both surgical and medical journals were explored RESULTS: It is proposed that effort thrombosis be classified as a secondary cause of UEDVT, limiting the definition of primary to that which is truly idiopathic. Other causes of secondary UEDVT include catheter- and pacemaker-related thrombosis (the most common cause, but often asymptomatic), thrombosis related to malignancy and hypercoagulable conditions, and the rare case of thrombosis due to compression of the vein by a focal malignancy or other space-occupying lesion. In true primary UEDVT and in those secondary cases where no mechanical cause is present or can be corrected, anticoagulation remains the treatment of choice, usually for three months or the duration of a needed catheter. However, evidence suggests that many cases of effort thrombosis are likely missed by a too-narrow adherence to this protocol.

CONCLUSIONS

Because proper treatment of effort thrombosis drops the long-term symptomatic status rate from 50% to almost zero and these are healthy patients with a long lifespan ahead, it is proposed that a more aggressive attitude toward thrombolysis be followed in any patient who has a reasonable degree of suspicion for venous thoracic outlet syndrome.

Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet

OBJECTIVE

Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy.

METHODS

We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection.

RESULTS

During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months.

CONCLUSIONS

Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.

Forearm Volume Changes Estimated by Photo-Plethysmography During an Original Candlestick/Prayer Maneuver in Patients With Suspected Thoracic Outlet Syndrome

Objective: Hemodynamic investigations in thoracic outlet syndrome (TOS) remain difficult, even in trained hands. Results are generally reported as either presence or absence of venous compression. In fact, in patients with suspected TOS but without chronic venous occlusion, the forearm volume changes may result from various combinations of forearm position from heart level, arterial inflow, and/or venous outflow positional impairment.

Design: Cross sectional, retrospective, single center study, accessible on Clinicaltrial.gov under reference NCT04376177.

Material: We used venous photo-plethysmography (V-PPG) in 151 patients with suspected TOS. The subjects elevated their arms to the “candlestick” (Ca) position for 30 s and then kept their arm elevated in front of the body for an additional 15 s (“prayer” position; Pra). This CA–Pra procedure was repeated three times by each patient with recording of both arms.

Method: We classified V-PPG recordings using an automatic clustering method.

Result: The blinded clustering classification of 893 V-PPG recordings (13 missing files) resulted in four out of seven clusters, allowing the classification of more than 99% of the available recordings. Each cluster included 65.73, 6.16, 17.13, and 10.8% of the recordings, respectively.

Conclusion: Venous hemodynamic profiles in TOS are not only either normal or abnormal. With V-PPG, four clusters were observed to be consistent with, and assumed to result from, the four possible associations of presence/absence of arterial inflow/venous outflow positional impairment: (1) normal response (maximal emptying in Ca and Pra), (2) isolated inflow impairment (emptying in Ca and filling in Pra due to post-ischemic vasodilation), (3) isolated venous outflow impairment (emptying then filling in Ca due to arterial inflow and emptying in Pra), and (4) simultaneous inflow/outflow impairment (emptying in Ca but no filling due to concomitant inflow impairment and further emptying in Pra).

How Common Is Thoracic Outlet Syndrome?

The incidence of neurogenic thoracic outlet syndrome is completely unknown, and has been wildly overestimated in the past. Based on a prospectively maintained database at our academic Thoracic Outlet Center, we estimate the yearly incidence of neurogenic and venous thoracic outlet syndrome to be approximately 3 and 1 per 100,000 population, respectively. The ratio of neurogenic to venous thoracic outlet syndrome seems to be approximately 80:20 based on presentation, and 75:25 based on operative correction. These data will help to understand the impact of these disorders, and perhaps help to guide resource management.

Surgical management of post-thrombotic syndrome in chronic venous thoracic outlet syndrome

OBJECTIVE

Venous thoracic outlet syndrome (VTOS) is considered chronic when symptoms and venous stenosis or occlusion are present for >3 months after the initial primary upper extremity deep vein thrombosis event. Many of patients with chronic VTOS receive conservative treatment. However, a subset of these patients will have persistent post-thrombotic syndrome symptoms because of underlying causative anatomy. We present the results of a same admission treatment consisting of' transaxillary thoracic outlet decompression (TA-TOD), external venolysis, and, if necessary, treatment of residual intraluminal lesions with percutaneous transluminal angioplasty (PTA) for chronic VTOS.

METHODS

All patients presenting from January 2015 to December 2019 with chronic VTOS and post-thrombotic syndrome complaints were evaluated. Patients with some degree of patency on venography or a chronic occlusion that could be recanalized using PTA preoperatively underwent TA-TOD, external venolysis, and immediate venography. Low-pressure diagnostic balloon inflation after first rib resection was used to identify residual lesions not evident by venography. If found, PTA was performed. Stent placement was reserved for patients with recurrent complaints due to residual lesions that had not been effectively treated by PTA.

RESULTS

A total of 40 patients with chronic VTOS were evaluated, of whom 36 were included and treated according to the protocol. The remaining four patients had had a chronic occlusion that could not be recanalized preoperatively and these patients were, therefore, excluded. After TA-TOD, immediate venography showed patent vessels with residual stenosis in 31 patients. Of the five patients who had appeared to have no significant stenosis on venography, two showed narrowing with diagnostic balloon inflation of the subclavian vein, for a total of 33 patients (92%) with residual stenosis after TA-TOD. All 33 patients underwent formal venous PTA. Complications occurred in five patients. At a mean follow-up of 24 months, 30 of the 36 patients (83%) were free of symptoms. The mean thoracic outlet syndrome disability scale score was 1.97 ± 1.9. The mean Disability of the Arm Shoulder and Hand scale score was 16.16 ± 17.4. The median VEINES (venous insufficiency epidemiologic and economic study)-symptoms score was 53.90 (interquartile range, 10.54). The median VEINES-quality of life (QOL) score was 54.22 (interquartile range, 13.93). Finally, the mean 12-item short-form physical QOL component scale score was 47.97 ± 9.02. The thoracic outlet syndrome disability scale and Disability of the Arm Shoulder and Hand scale scores had significantly decreased (P < .01), and the 12-item short-form physical QOL component scale score had significantly improved (P < .01) compared with the baseline scores. A return to daily activities was achieved by 93% of the patients.

CONCLUSIONS

The treatment of patients with chronic VTOS using a same admission treatment algorithm consisting of TA-TOD, external venolysis, and PTA is effective. Intermediate follow-up showed a high return to daily activity and significant improvement in functional outcome and physical QOL.

Percutaneous Extra-Anatomic Double-Barrel Bypass for Salvage of Hemodialysis Access and Treatment of Venous Occlusive Disease

A woman with an upper extremity brachioaxillary arteriovenous dialysis graft presented with a 9-month history of profound ipsilateral arm swelling and numbness secondary to chronic axillosubclavian vein occlusion. Previous endovascular and open venous recanalization attempts were unsuccessful. A totally percutaneous extra-anatomic venous bi-bypass was created to salvage the dialysis access circuit and reconstruct the deep venous system. Using overlapping Viabahn stent-grafts, two parallel bypasses were created from the arteriovenous graft and brachial vein, respectively, to the brachiocephalic vein. The hemodialysis graft regained function. Upper extremity symptoms resolved within 48 h. This is the first reported percutaneous double-barrel technique of extra-anatomic venous bypass creation for simultaneous management of a failed dialysis access and chronic venous occlusive disease.

The Incidence of Thoracic Outlet Syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) refers to a constellation of compressive problems that occur at the thoracic outlet. TOS has been recognized since the 19th century, and the "modern" era of treatment, especially for neurogenic TOS, dates from at least the 1970s. Despite this, however, the incidence and prevalence of these syndromes are almost completely unknown. To attempt to answer this fundamental question, we established a prospective database of all patients who presented to our clinic with a diagnosis of potential TOS, as described below.

METHODS

We established a database of all patients referred to our clinic from July 1, 2014 to May 2018. All subjective data, the tentative diagnosis, and plan at the time of the office visit were prospectively recorded. For patients with neurogenic TOS (NTOS), a standardized workup sheet was used based on the Society for Vascular Surgery's recently published reporting standards document. For patients with venous TOS (VTOS), diagnosis was made by clinical examination and ultrasound, and for those with arterial TOS (ATOS), by clinical examination, ultrasound, and cross-sectional imaging when needed.

RESULTS

From July 1, 2014, to May 1, 2018, 526 patients were referred to our institution with a diagnosis of possible TOS. Of these, 432 (82%) were referred with symptoms suggestive of NTOS, 84 (16%) with symptoms suggestive of VTOS, and 10 (2%) with findings and/or symptoms suggestive of ATOS. NTOS: After evaluation as per the algorithm previously mentioned, 234 patients (54%) were judged high suspicion for NTOS, 126 (30%) moderate suspicion, and 72 (17%) low suspicion; 360 (83%) of those originally referred were felt to potentially have NTOS. Of the 84 patients with VTOS, 25 (30%) presented with acute Paget-Schroetter syndrome, 41 (48%) with subacute or chronic occlusion, and 18 (21%) with McCleery's syndrome. Finally, 8 of the 10 limbs had true ATOS; of these, 6 (75%) underwent decompression and repair and 2 (25%) endovascular intervention only. Based on referral assumptions and population density in our area, the incidence of NTOS seems to be between 2 and 3 cases per 100,000 people per year and that of VTOS between 0.5 and 1 per 100,000 people per year, ATOS being sporadic. The ratio of those with decent suspicion for NTOS and VTOS, respectively, is about 80:20, whereas that of those undergoing surgical decompression is about 75:25.

CONCLUSIONS

The rates of NTOS and VTOS, as aforementioned, are approximately 25 and 8 per year in a metropolitan area of 1,000,000, respectively. Although a rare disease, these numbers are not insignificant, although are much lower than prior estimates.

Paget-Schroetter syndrome: A contemporary review of the controversies in management

Aim

To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome.

Materials and methods

We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome.

Results

There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed.

Conclusions

Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.

Infraclavicular Thoracic Outlet Decompression Compared to Supraclavicular Thoracic Outlet Decompression for the Management of Venous Thoracic Outlet Syndrome

BACKGROUND

The treatment of venous thoracic outlet syndrome (VTOS) requires surgical decompression often combined with catheter-directed thrombolysis and venoplasty. Surgical options include transaxillary, supraclavicular, or infraclavicular approaches to first rib resection. The optimal method, however, has yet to be defined. The purpose of this study is to compare the outcomes of patients who underwent infraclavicular versus supraclavicular surgical decompression for VTOS.

METHODS

A retrospective review of patients who underwent surgical management for VTOS from December 2010 to November 2017 was performed. During the study period, supraclavicular and infraclavicular approaches were chosen according to surgeon preference. Patient demographics, pre- and postdecompression interventions, perioperative outcomes for each group of patients were analyzed.

RESULTS

Thirty patients underwent surgical management of VTOS, of which 15 (50%) underwent infraclavicular decompression and 15 (50%) supraclavicular decompression. The mean age of patients was 32.1 ± 13.6 years and 80% were male. Twenty-six patients (86.7%) presented with thrombotic VTOS. Acute axillosubclavian vein thrombosis was present in 20 (76.9%) of these patients, 10 patients in each group. Subacute or chronic thrombosis was encountered in the remaining 6 (23%) patients, 2 patients in the infraclavicular group and 4 patients in the supraclavicular group. Preoperative thrombolysis was utilized in 7 (46.7%) and 6 (40%) patients in the infraclavicular and supraclavicular groups, respectively (P = 1.00). Patients without postdecompression venography were removed from analysis and included 1 patient in the infraclavicular group and 5 patients in the supraclavicular group. Initial postdecompression venogram, prior to any endovascular intervention, demonstrated a residual axillosubclavian vein stenosis of greater than 50% in 6 (42.9%) patients in the infraclavicular decompression group and 7 (70%) patients in the supraclavicular decompression group (P = 0.24). Crossing the stenosis after surgical decompression was more easily accomplished in the infraclavicular group, 14 (100%) versus 5 (50%), (P = 0.01). Following endovascular venoplasty, calculated residual stenosis greater than 50% was found in 0 (0%) and 3 (30%) patients in the infraclavicular and supraclavicular approaches, respectively (P = 0.047). Infraclavicular thoracic outlet decompression was associated with fewer patients with postoperative symptoms, 0 of 15 (0%) versus 8 of 15 (53.3%), (P = 0.0022), and infraclavicular thoracic outlet decompression demonstrated improved patency, 15 of 15 (100%) versus 8 of 15 (53.3%), (P = 0.028) at a mean combined follow-up of 8.47 ± 10.8 months.

CONCLUSIONS

Infraclavicular thoracic outlet decompression for the surgical management of VTOS was associated with fewer postoperative symptoms and improved axillosubclavian vein patency compared to the supraclavicular approach. Prospective analysis is warranted to determine long-term outcomes following infraclavicular decompression.