Analysis of Completion Intraoperative Venography Findings During First Rib Resection for Venous Thoracic Outlet Syndrome

Traditional treatment of venous thoracic outlet syndrome (vTOS) is first rib resection (FRR) and subclavian venolysis followed by interval venography with possible angioplasty. Completion intraoperative venography has emerged as an effective alternative, but clinical outcomes have yet to be correlated with operative findings. The goal of the current study was to review our institutions’ use of completion intraoperative venography and analyze outcomes based on venographic findings. All patients with vTOS treated with FRR at Thomas Jefferson University Hospital from 2011 to 2021 were analyzed via a retrospective chart review. Venography was performed after FRR intraoperatively with the arm in neutral and abducted position for all patients. Venography results were reviewed in the operative report, and patients were grouped into one of four categories: (1) no initial stenosis, (2) stenosis + angioplasty with complete resolution, (3) stenosis + angioplasty with residual stenosis, and (4) stenosis without intervention. The primary outcome was axillosubclavian vein primary and primary-assisted patency at 3 months and 1 year. Secondary outcomes included freedom from symptoms, rate of reintervention, and perioperative complication rate. Descriptive statistics were performed using GraphPad Prism version 9.3.1. A total of 32 patients (mean age, 30.2 ± 11 years, 56.3% male) were treated for vTOS with FRR and intraoperative venography with a mean follow-up of 17.8 ± 14.3 months. Preoperative anticoagulation was used in 30 (93.7%) patients with a direct oral anticoagulant (Xeralto or Eliquis) being the most common at 56.7%. Venographic findings identified 10 patients (31.3%) with no initial stenosis, 10 (31.3%) with stenosis and complete resolution after angioplasty, 4 (12.5%) with residual stenosis despite angioplasty, and 8 (25%) with significant stenosis not intervened upon. Overall, 3-month and 1-year primary patency was 96.8% and 90.9%, respectively. Two patients (6.25%) required reintervention with repeat venogram and angioplasty. Six of 8 patients (75%) with stenosis were not intervened because of difficulty crossing the stenosis, and all 6 of these patients had extensive collaterals identified on venography. Patient demographics, venography findings, and outcomes can be found in the Table. Our single institutional study demonstrates that FRR with completion intraoperative venography has excellent short- and midterm patency rates despite different venographic outcomes. Patients with residual axillosubclavian vein stenosis had similar symptomatic relief and protection from recurrent DVT as those with no significant residual venous stenosis, likely due to collateral formation.TablePatient demographics, venographic findings, and outcomes (N = 32)Patient demographics and outcomesValues, No. (%)Female sex14 (43.7)Mean age ± SD, years30.2 ± 11.1Right upper extremity22 (68.7)Catheter-directed venolysis before FRR17 (53.1)Chronic presentation8 (25)Preoperative AC30 (93.7)Preoperative AC class Coumadin12 (40) DOAC17 (56.7) Lovenox1 (3.3)Preoperative AC, mean ± SD, days105.3 ± 143.3Venography groups No initial stenosis10 (31.3) Stenosis + angioplasty with resolution10 (31.3) Stenosis + angioplasty with residual stenosis4 (12.5) Stenosis without angioplasty8 (25)Extensive collaterals identified9 (28.1)Operative mortality0Perioperative complication rate4 (12.5)Discharge AC bASA11 (34.4) Coumadin5 (15.6) DOAC13 (40.6) Lovenox1 (3.3) None2 (6.2)Bleeding complication2 (6.25)Rethrombosis0Reintervention rate2 (6.25)3-month primary patency31/32 (96.8)3-month Primary-assisted patency32/32 (100)1-year primary patency20/22 (90.9)1-year primary-assisted patency22/22 (100)Length of follow-up mean months ± SD17.8 ± 14.3Free from symptoms, mean months ± SD15.4 ± 12.9AC, Anticoagulation; bASA, aspirin 81 mg; DOAC, direct oral anticoagulant; FRR, first rib resection; SD, standard deviation. Open table in a new tab