Safety and efficacy of catheter directed therapies in venous thoracic outlet syndrome

Thoracic outlet syndrome (TOS) describes a set of disorders resulting from anatomic compression of the brachial plexus, subclavian artery or subclavian vein. Venous TOS may present with upper extremity swelling, pain or deep venous thrombosis (DVT). Management of venous TOS is controversial, with catheter directed therapies such as thrombolysis and angioplasty often supplementing surgical decompression. We retrospectively evaluate a single-center series of venous TOS patients. Retrospective analysis of consecutive patients who underwent venography at our institution for venous TOS was performed. 69 patients with venous TOS symptoms from January 2004 to September 2014 were identified. Patient parameters, presenting symptoms, endovascular and surgical management and clinical follow-up were recorded. Of the 69 patients, 43 (62%) were diagnosed with venous TOS due to acute upper extremity DVT with 34 (34/43, 79%) undergoing catheter directed thrombolysis and angioplasty. The remaining patients (26/69, 38%) presented with chronic symptoms of venous hypertension. 69 patients underwent venography with 60 (87%) having evidence of TOS on at least one side (19 bilaterally). 53 (53/60, 88%) underwent surgical decompression. Of 38 patients with documented left or right hand dominance and unilateral decompression, 55% (21/38) required ipsilateral decompression and 45% the non-dominant side. Of the 53 undergoing decompression, 45 (85%) had post-surgical venography. 39 (39/45, 87%) required angioplasty, 3 had no angiographic stenosis and 3 had chronic subclavian vein occlusion. Of 39 patients with post-decompression angioplasty, only 4 (10%) had repeat venography due to non-resolution or recurrence of symptoms, while 35 (35/39, 90%) remained symptom-free. Average follow-up was 36 months. Although no complications from venography or angioplasty were reported, 1 patient developed thrombolysis-related heparin induced thrombocytopenia. Venography, angioplasty, and thrombolysis are safe procedures in treatment of venous TOS. The majority of patients undergoing surgical decompression required post-procedure angioplasty, with good long-term results and low recurrence of venous TOS symptoms.