Methods
Two vascular surgeons (IW/RJW) who routinely perform thoracic outlet
surgery at University Hospital of Wales were included in the series. All
patients presenting with a suspected diagnosis of PSS underwent complete
history and examination followed by X-Ray of the thoracic inlet and
duplex ultrasonography to confirm the diagnosis. If a thrombus was
detected in the SV and there were no contraindications, a full
discussion was held with the patient regarding venography and possible
thrombolysis. The risks of thrombolysis were explained as were the
potential benefits and if consenting underwent open surgical
decompression following lysis. The selection of patients to undergo
surgical decompression takes into account several factors. These include
the age, whether it is the dominant arm affected, the duration of the
thrombus within the vein, acceptance of risks of lysis and open surgery.
Furthermore, if treated medically there is a risk of developing post
phlebitic limb and associated morbidity in up to 46% of
cases.13 Patients were initially treated with CDTL
using tPA via the ipsilateral cephalic vein, at 1 mL/hr after a 10 mg
bolus dose. This was repeated after 6 hours with a further venogram
performed within 24 hours. tPA was either continued (for 6 further
hours) or discontinued, depending on the residual thrombus load within
the SV. Surgical decompression was then carried out in accordance with
the IC, TA, and SC routes outlined previously, and all patients
underwent first rib resection (FRR) under general anaesthetic. Patients
were then commenced on antiplatelet therapy (aspirin) combined with 3-6
months of anticoagulation and latterly rivaroxaban. This was then
stopped and antiplatelets were continued long-term. Venography was
performed at six weeks post-surgery to assess patency and to treat
residual stenosis if present.