Current trends in the treatment of venous thoracic outlet syndrome: a comprehensive review

Endovascular management of acute and subacute venous thoracic outlet syndrome

Approximately 3% of all patients presenting with Thoracic Outlet Syndrome have a venous etiology (vTOS), which is considered "effort thrombosis". These patients will present with symptomatic deep venous thrombosis or focal subclavian vein (SCV) stenosis. Endovascular management of vTOS occurs in several phases: diagnostic, preoperative therapeutic intervention before decompression, postoperative interventions after decompression, and delayed interventions in the follow-up after decompression. In the diagnostic phase, dynamic SCV venography can establish functional vTOS. Approximately 4,000 patients have been treated for vTOS and reported in the literature since 1970. Declotting of the SCV was followed by surgical decompression in 53% of patients, while in the remainder, surgical decompression alone (18%), endovascular intervention alone (15%), or conservative therapy with anticoagulation (15%) was performed. The initial intervention was predominantly catheter-directed thrombolysis, with <10% of cases undergoing concomitant balloon angioplasty. 93% of cases were successful. In the postoperative phase, balloon angioplasty was performed to correct residual intrinsic SCV disease after vTOS decompression in under 15% of cases. Stents were rarely deployed. Symptom relief was reported as 94 ± 12% (mean ± SD) and 90 ± 23%, respectively for declotting with decompression and declotting alone. In the delayed phase, balloon angioplasty was performed in under 15% of cases to re-establish patency.

How I do it. Thoracic outlet syndrome and the transaxillary approach

Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach.

Atypical Presentation of Paget-Schroetter Syndrome: Case Report and Management

Upper extremity deep vein thrombosis (UEDVT) is a rare condition that makes early clinical evaluation and treatment important prior to the formation of deep vein thrombosis (DVT). Typical risk factors include male sex, young age, repetitive arm over abduction and hyperextension, indwelling catheters, cervical first rib, and thoracic outlet syndrome. One common cause of UEDVT is Paget-Schroetter syndrome (PSS). If untreated, pulmonary complications such as venous thromboembolic disease and pulmonary embolism (PE) may develop. We present a case of a 34-year-old Caucasian female who presented to the emergency department with sudden, acute right arm pain after blow-drying her hair, consistent with UEDVT. CT angiography (CTA) demonstrated moderate thromboembolic disease within segmental and subsegmental branches of the left upper, left lower, and right lower lobes. Ultrasonography (US) of the upper extremity showed non-compressibility of the right axillary and basilic vein, a finding consistent with acute DVT. Peripheral angiogram revealed imaging consistent with undiagnosed thoracic outlet syndrome secondary to effort thrombosis. The patient deferred surgical intervention and agreed to begin long-term anticoagulation therapy. PSS requires immediate recognition and treatment to prevent possible long-term neurologic and vascular compromise. Despite the patient lacking the typical population demographics, PSS should be considered given the patient's symptoms and presentation. Recognition of UEDVT despite classic signs and symptoms consistent with known risk factors is imperative upon clinical suspicion. Delay in clinical management may lead to fatal complications. We aim to highlight a case of PSS along with alternative pathways for treatment delivery.

Multidisciplinary management of Paget-Schroetter syndrome. A case series of eight patients

Paget-Schroetter syndrome (PSS) in the context of upper extremity deep venous thrombosis (DVT) is an uncommon but potentially very serious condition affecting young, healthy adults, in which secondary post-thrombotic syndrome (PTS) can be a complication with major implications. The best treatment option remains controversial, with current guidelines recommending anticoagulation for at least 3 months. However, an incidence of PTS of approximately 50% after 6 months, 30% after 1 year and 25% after 2 years has been found using this therapeutic approach. Consequently, specialized units recommend local thrombolysis and early decompressive surgery. We describe a series of eight cases treated in this way. None of the patients showed signs of complications, and an early return to regular activities with no PTS was observed in 90% of cases.