Infraclavicular Approach and Adjunctive Strategies for the Management of Venous Thoracic Outlet Syndrome

Venous thoracic outlet syndrome (VTOS) traditional management has involved catheter-directed thrombolysis (CDT) followed by transaxillary (TA) or paraclavicular (PC) first rib resection. Our previous study showed an infraclavicular (IC) approach with adjunctive balloon angioplasty, along with the other strategies, demonstrated low perioperative morbidity, excellent subclavian vein patency rates, and shorter operative times compared with a TA or PC approach. We report midterm follow-up for the IC approach for the treatment of acute VTOS. A retrospective review of patients treated for VTOS were identified using our prospectively maintained database over a 30-year period. All patients undergoing first rib resection for VTOS from January 1993 to January 2023 at Pennsylvania Hospital were included for analysis. Our previously published operative strategy was performed, which includes CDT with pharmacomechanical thrombectomy followed by IC first rib resection during the same hospitalization, with adjunctive subclavian vein angioplasty immediately after rib resection. A total of 59 patients underwent first rib resection for VTOS, 48 (81%) via an IC approach and 11 (19%) through a PC approach. The average patient age was 40 years, and the majority were female (43 [73%]). The majority of VTOS involved the right subclavian vein (40 [68%]), and all patients underwent preoperative CDT. The average operative time was shorter for an IC compared with PC approach. Primary and primary-assisted patency rates were excellent. There were no significant differences in patency rates or complications between the IC and PC approaches. Our IC first rib resection approach with adjunctive balloon angioplasty at the time of decompression further demonstrated excellent subclavian vein patency rates, shorter operative times, and better midterm outcomes compared with TA or PC approaches.