Outcomes After Treatment of VTOS



The study of venous thoracic outlet syndrome (VTOS), while apparently as objective an entity as any within this family of disorders, suffers from a lack of objectivity when results are reported. The literature is not consistent regarding how VTOS is diagnosed or results are described. VTOS is a spectrum of clinical problems, some representing acute issues and others chronic disease states. Most reports lump all patients together, there is little consistency with regard to outcomes reporting, and there are no prospective randomized studies. As a result, there is lack of consensus on how to treat these patients and no high-level evidence-based recommendations for care. This chapter attempts to describe outcomes within these constraints, but it is stressed that to truly understand this syndrome we must agree on criteria for diagnosis, acceptable methods of treatment, and consistent standards for reporting outcomes.


Stent Placement Treatment Algorithm Clinical Pathway Surgical Decompression Decompressive Surgery 
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  1. 1.
    Hughes E. Venous obstruction upper extremity: review of 320 cases. Int Abst Surg. 1949;88:89–127.Google Scholar
  2. 2.
    Adams JT, DeWeese JA. “Effort” thrombosis of the axillary and subclavian veins. J Trauma. 1971;11:923–30.PubMedCrossRefGoogle Scholar
  3. 3.
    AbuRahma AF, Sadler D, Stuart P, Khan MZ, Boland JP. Conventional versus thrombolytic therapy in spontaneous (effort) axillary-subclavian vein thrombosis. Am J Surg. 1991;161:459–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Becker DM, Philbrick JT, Walker FB. Axillary and subclavian venous thrombosis. Prognosis and treatment. Arch Intern Med. 1991;151:1934–43.PubMedCrossRefGoogle Scholar
  5. 5.
    Heron E, Lozinguez O, Emmerich J, Laurian C, Fiessinger JN. Long-term sequelae of spontaneous axillary-subclavian venous thrombosis. Ann Intern Med. 1999;131:510–3.PubMedCrossRefGoogle Scholar
  6. 6.
    Monreal M, Lafoz E, Ruiz J, Valls R, Alastrue A. Upper-extremity deep venous thrombosis and pulmonary embolism. A prospective study. Chest. 1991;99:280–3.PubMedCrossRefGoogle Scholar
  7. 7.
    Tilney N, Griffiths H, Edwards E. Natural history of major venous thrombosis of the upper extremity. Arch Surg. 1970;101:792–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Urschel Jr HC, Razzuk MA. Paget-Schroetter syndrome: what is the best management? Ann Thorac Surg. 2000;69:1663–8; discussion 8–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Adams J, McEvoy R, DeWeese J. Primary deep venous thrombosis of upper extremity. Arch Surg. 1965;91:29–42.CrossRefGoogle Scholar
  10. 10.
    Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet syndrome. Ann Surg. 1966;163:354–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Inahara T. Surgical treatment of “effort” thrombosis of the axillary and subclavian veins. Am Surg. 1968;34:479–83.PubMedGoogle Scholar
  12. 12.
    Swinton Jr NW, Edgett Jr JW, Hall RJ. Primary subclavian-axillary vein thrombosis. Circulation. 1968;38:737–45.PubMedCrossRefGoogle Scholar
  13. 13.
    DeWeese JA, Adams JT, Gaiser DL. Subclavian venous thrombectomy. Circulation. 1970;41:II158–64.PubMedCrossRefGoogle Scholar
  14. 14.
    Doyle A, Wolford HY, Davies MG, et al. Management of effort thrombosis of the subclavian vein: today’s treatment. Ann Vasc Surg. 2007;21:723–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Freischlag J. Venous thoracic outlet syndrome: transaxillary approach. Oper Tech Gen Surg. 2008;10:122–30.CrossRefGoogle Scholar
  16. 16.
    Lee JT, Karwowski JK, Harris EJ, Haukoos JS, Olcott C. Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg. 2006;43:1236–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg. 1993;17:305–15; discussion 16–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Molina JE, Hunter DW, Dietz CA. Paget-Schroetter syndrome treated with thrombolytics and immediate surgery. J Vasc Surg. 2007;45:328–34.PubMedCrossRefGoogle Scholar
  19. 19.
    Schneider DB, Dimuzio PJ, Martin ND, et al. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty. J Vasc Surg. 2004;40:599–603.PubMedCrossRefGoogle Scholar
  20. 20.
    Urschel Jr HC, Patel AN. Surgery remains the most effective treatment for Paget-Schroetter syndrome: 50 years’ experience. Ann Thorac Surg. 2008;86:254–60; discussion 60.PubMedCrossRefGoogle Scholar
  21. 21.
    Becker GJ, Holden RW, Rabe FE, et al. Local thrombolytic therapy for subclavian and axillary vein thrombosis. Treatment of the thoracic inlet syndrome. Radiology. 1983;149:419–23.PubMedGoogle Scholar
  22. 22.
    Perler BA, Mitchell SE. Percutaneous transluminal angioplasty and transaxillary first rib resection. A multidisciplinary approach to the thoracic outlet syndrome. Am Surg. 1986;52:485–8.PubMedGoogle Scholar
  23. 23.
    Taylor Jr LM, McAllister WR, Dennis DL, Porter JM. Thrombolytic therapy followed by first rib resection for spontaneous (“effort”) subclavian vein thrombosis. Am J Surg. 1985;149:644–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Zimmermann R, Morl H, Harenberg J, Gerhardt P, Kuhn HM, Wahl P. Urokinase therapy of subclavian-axillary vein thrombosis. Klin Wochenschr. 1981;59:851–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Adelman MA, Stone DH, Riles TS, Lamparello PJ, Giangola G, Rosen RJ. A multidisciplinary approach to the treatment of Paget-Schroetter syndrome. Ann Vasc Surg. 1997;11:149–54.PubMedCrossRefGoogle Scholar
  26. 26.
    Wilson JJ, Zahn CA, Newman H. Fibrinolytic therapy for idiopathic subclavian-axillary vein thrombosis. Am J Surg. 1990;159:208–10; discussion 10–1.PubMedCrossRefGoogle Scholar
  27. 27.
    Guzzo JL, Chang K, Demos J, Black JH, Freischlag JA. Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis. J Vasc Surg. 2010;52:658–63.PubMedCrossRefGoogle Scholar
  28. 28.
    Green RM, Waldman D, Ouriel K, Riggs P, Deweese JA. Claviculectomy for subclavian venous repair: long-term functional results. J Vasc Surg. 2000;32:315–21.PubMedCrossRefGoogle Scholar
  29. 29.
    Molina JE. Need for emergency treatment in subclavian vein effort thrombosis. J Am Coll Surg. 1995;181:414–20.PubMedGoogle Scholar
  30. 30.
    Lee MC, Grassi CJ, Belkin M, Mannick JA, Whittemore AD, Donaldson MC. Early operative intervention after thrombolytic therapy for primary subclavian vein thrombosis: an effective treatment approach. J Vasc Surg. 1998;27:1101–7; discussion 7–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Sundqvist SB, Hedner U, Kullenberg HK, Bergentz SE. Deep venous thrombosis of the arm: a study of coagulation and fibrinolysis. Br Med J (Clin Res Ed). 1981;283:265–7.CrossRefGoogle Scholar
  32. 32.
    Bjarnason H, Hunter DW, Crain MR, Ferral H, Miltz-Miller SE, Wegryn SA. Collapse of a Palmaz stent in the subclavian vein. AJR Am J Roentgenol. 1993;160:1123–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Meier GH, Pollak JS, Rosenblatt M, Dickey KW, Gusberg RJ. Initial experience with venous stents in exertional axillary-subclavian vein thrombosis. J Vasc Surg. 1996;24:974–81; discussion 81–3.PubMedCrossRefGoogle Scholar
  34. 34.
    Urschel Jr HC, Patel AN. Paget-Schroetter syndrome therapy: failure of intravenous stents. Ann Thorac Surg. 2003;75:1693–6; discussion 6.PubMedCrossRefGoogle Scholar
  35. 35.
    Angle N, Gelabert HA, Farooq MM, et al. Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg. 2001;15:37–42.PubMedGoogle Scholar
  36. 36.
    Caparrelli DJ, Freischlag J. A unified approach to axillosubclavian venous thrombosis in a single hospital admission. Semin Vasc Surg. 2005;18:153–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Urschel Jr HC, Razzuk MA. Neurovascular compression in the thoracic outlet: changing management over 50 years. Ann Surg. 1998;228:609–17.PubMedCrossRefGoogle Scholar
  38. 38.
    Druy EM, Trout 3rd HH, Giordano JM, Hix WR. Lytic therapy in the treatment of axillary and subclavian vein thrombosis. J Vasc Surg. 1985;2:821–7.PubMedGoogle Scholar
  39. 39.
    Machleder HI. Thrombolytic therapy and surgery for primary axillosubclavian vein thrombosis: current approach. Semin Vasc Surg. 1996;9:46–9.PubMedGoogle Scholar
  40. 40.
    Strange-Vognsen HH, Hauch O, Andersen J, Struckmann J. Resection of the first rib, following deep arm vein thrombolysis in patients with thoracic outlet syndrome. J Cardiovasc Surg (Torino). 1989;30:430–3.Google Scholar
  41. 41.
    Altobelli GG, Kudo T, Haas BT, Chandra FA, Moy JL, Ahn SS. Thoracic outlet syndrome: pattern of clinical success after operative decompression. J Vasc Surg. 2005;42:122–8.PubMedCrossRefGoogle Scholar
  42. 42.
    de Leon RA, Chang DC, Hassoun HT, et al. Multiple treatment algorithms for successful outcomes in venous thoracic outlet syndrome. Surgery. 2009;145:500–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 2010;51:1538–47.PubMedCrossRefGoogle Scholar
  44. 44.
    Sheeran SR, Hallisey MJ, Murphy TP, Faberman RS, Sherman S. Local thrombolytic therapy as part of a multidisciplinary approach to acute axillosubclavian vein thrombosis (Paget-Schroetter syndrome). J Vasc Interv Radiol. 1997;8:253–60.PubMedCrossRefGoogle Scholar
  45. 45.
    Stone DH, Scali ST, Bjerk AA, et al. Aggressive treatment of idiopathic axillo-subclavian vein thrombosis provides excellent long-term function. J Vasc Surg. 2010;52:127–31.PubMedCrossRefGoogle Scholar
  46. 46.
    Illig KA. An improved method of exposure for transaxillary first rib resection. J Vasc Surg. 2010;52:248–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Thompson RW. Venous thoracic outlet syndrome: paraclavicular approach. Oper Tech Gen Surg. 2008;10:113–21.CrossRefGoogle Scholar
  48. 48.
    Molina JE. Approach to the confluence of the subclavian and internal jugular veins without claviculectomy. Semin Vasc Surg. 2000;13:10–9.PubMedGoogle Scholar
  49. 49.
    Molina JE, Hunter DW, Dietz CA. Protocols for Paget-Schroetter syndrome and late treatment of chronic subclavian vein obstruction. Ann Thorac Surg. 2009;87:416–22.PubMedCrossRefGoogle Scholar
  50. 50.
    Berzaczy D, Popovic M, Reiter M, et al. Quality of life in patients with idiopathic subclavian vein thrombosis. Thromb Res. 2010;125:25–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Chang DC, Rotellini-Coltvet LA, Mukherjee D, De Leon R, Freischlag JA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg. 2009;49:630–5; discussion 5–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Hall LD, Murray JD, Boswell GE. Venous stent placement as an adjunct to the staged, multimodal treatment of Paget-Schroetter syndrome. J Vasc Interv Radiol. 1995;6:565–9; discussion 9–70.PubMedCrossRefGoogle Scholar
  53. 53.
    Kreienberg PB, Chang BB, Darling 3rd RC, et al. Long-term results in patients treated with thrombolysis, thoracic inlet decompression, and subclavian vein stenting for Paget-Schroetter syndrome. J Vasc Surg. 2001;33:S100–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Hempel GK, Shutze WP, Anderson JF, Bukhari HI. 770 consecutive supraclavicular first rib resections for thoracic outlet syndrome. Ann Vasc Surg. 1996;10:456–63.PubMedCrossRefGoogle Scholar
  55. 55.
    Azakie A, McElhinney DB, Thompson RW, Raven RB, Messina LM, Stoney RJ. Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression. J Vasc Surg. 1998;28:777–86.PubMedCrossRefGoogle Scholar
  56. 56.
    Feugier P, Aleksic I, Salari R, Durand X, Chevalier JM. Long-term results of venous revascularization for Paget-Schroetter syndrome in athletes. Ann Vasc Surg. 2001;15:212–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Coletta JM, Murray JD, Reeves TR, et al. Vascular thoracic outlet syndrome: successful outcomes with multimodal therapy. Cardiovasc Surg. 2001;9:11–5.PubMedCrossRefGoogle Scholar
  58. 58.
    Lokanathan R, Salvian AJ, Chen JC, Morris C, Taylor DC, Hsiang YN. Outcome after thrombolysis and selective thoracic outlet decompression for primary axillary vein thrombosis. J Vasc Surg. 2001;33:783–8.PubMedCrossRefGoogle Scholar

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© Springer-Verlag London 2013

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Rochester Medical CenterRochesterUSA

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