Surgical Approaches to Venous Thoracic Outlet Syndrome and Complications: The Role of Interventional Radiology

Learning Objectives: • Discuss surgical approaches for definitive management of venous thoracic outlet syndrome (TOS) and associated complications
• Review post-operative opportunities for IR consultation
• Provide case examples of post-surgical subclavian vein interventions

Background:

Venous TOS (vTOS) patients who present with symptomatic acute deep venous thrombosis, are typically managed with catheter directed thrombectomy/thrombolysis followed by short interval elective decompressive surgery {1}.

Open surgical decompression approaches of thoracic outlet structures include claviculolectomy, scalenectomy, or rib removal via supraclavicular, infraclavicular, or transaxillary approaches. Thoracic surgeons may utilize robot-assisted approaches {2}.

Complications include pneumothorax, hemothorax, thoracic duct injury, injury to adjacent nerves, and--perhaps most pertinent to IR--subclavian vein stenosis, which can be intrinsic residual thrombus or extrinsic scarring and/or residual fibrotic bands {2,3}.

Some patients with residual symptoms may benefit from post-operative endovascular or repeat surgical management depending on the etiology, although routine post-operative venograms remain controversial {4,5}.

Clinical Findings/Procedure Details: 1. Overview of surgical techniques: pros and cons

• Supraclavicular–allows for extensive brachial plexus neurolysis, anterior rib, and/or costoclavicular ligament resection


• Infraclavicular–higher risk of brachial plexus injury, incomplete posterior rib resection


• Transaxillary- favorable cosmesis, difficult to achieve adequate exposure, requires brachial plexus compression during positioning


• Robot-assisted-allows for complete 1st rib and neurovascular bundle exposure

2. Overview of common complications: nerve injury, vascular injury, pneumothorax, and thoracic duct injury

3. IR management of persistent subclavian vein stenosis: diagnosis, pitfalls, and treatment options

• Physical exam findings of residual subclavian vein stenosis


• Distinguishing clinical findings of nerve and vascular injury


• The role of post-operative venograms


• Intrinsic residual thrombus vs extrinsic scarring/compression


• Select case examples of subclavian vein angioplasty

Conclusion and/or Teaching Points: Surgical approaches to vTOS vary with differing levels of anatomical exposure, which may be relevant in minimizing symptom recurrence. Interventional radiology plays a critical role in the management of post-operative vTOS patients in the consideration of endovascular management for recurrent disease.