Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients.

BACKGROUND: Subclavian vein stenosis or occlusion at the thoracic outlet is a problem associated with certain anatomic and environmental stresses (venous thoracic outlet syndrome [VTOS]), the presence of central venous catheters, and the high flows associated with arteriovenous (AV) access in the limb. We describe our experience with open and endovascular techniques for restoring patency in highly symptomatic patients. METHODS: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease in the setting of highly symptomatic VTOS and ipsilateral AV access from October 2011 to August 2016. RESULTS: During the study period, 54 procedures were performed in 53 patients (68% male; mean age, 50.1 years). Indications for operation were venous outflow obstruction in patients with conventional VTOS (n = 19) or costoclavicular junction stenosis associated with ipsilateral dialysis access (n = 34). All patients had significant symptoms of swelling or pain. Eight patients underwent on-table pharmacomechanical thrombolysis for acute occlusion. All patients underwent costoclavicular junction decompression, 48 by infraclavicular first rib resection and 5 by claviculectomy; 6 patients underwent sternoclavicular rotation (Molina procedure) in addition to rib resection for further exposure. Surgical reconstruction of the vein was employed in 18 patients (33%); 9 underwent interposition grafting, 1 had jugular turndown, and 8 had patch angioplasty. The one patient undergoing two procedures suffered acute occlusion after patch repair followed by jugular turndown. Four patients underwent surgical reconstruction after thrombolysis. Endovascular procedures were performed in 36 patients (67%); 23 underwent venous angioplasty alone, and 13, all with hemodialysis access-associated stenosis, underwent stenting. Mean operative time was 135 (±63.5) minutes, and mean estimated blood loss was 238 (±261) mL. Median length of stay was 4 days. Perioperative complications were noted in 14 (26.4%) patients, including wound complications (n = 6), cardiac complications (n = 4), reocclusion (n = 3), and hemothorax requiring chest tube placement (n = 1) in a patient undergoing on-table thrombolysis. Mean follow-up was 13.6 (0.6-58.5) months. Initial clinical symptom relief was experienced in 100% of patients at the time of hospital discharge. During follow-up, 5 (9.4%) patients developed recurrent symptoms, 6 (11.3%) had reocclusion of the central system, and 16 (30.2%) required reintervention for restenosis, all but 2 in patients with ipsilateral hemodialysis access. Mean time to reintervention was 134 (±285) days. CONCLUSIONS: Given our decision-making threshold, both open and endovascular procedures are associated with relatively low morbidity and high efficacy for treatment of central venous occlusion in both symptomatic VTOS and AV access-associated subclavian vein disease. Restenosis is common in patients with a patent ipsilateral hemodialysis access.

Outcomes of venous bypass combined with thoracic outlet decompression for treatment of upper extremity central venous occlusion.

BACKGROUND: Upper extremity central venous stenosis results from a variety of environmental and anatomic conditions, including venous thoracic outlet syndrome, the presence of device leads or catheters, and the turbulence created by the presence of arteriovenous fistulas or grafts. In cases of total occlusion, especially at the bony costoclavicular junction, options for endovascular treatment and open venous reconstruction are limited and bypass grafting may be needed. We describe our experience with venous bypass combined with thoracic outlet decompression in a cohort of symptomatic patients with subclavian vein occlusion. METHODS: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease with venous bypass in the setting of both symptomatic venous thoracic outlet syndrome and ipsilateral arteriovenous access from July 2012 to December 2017. All but one patient presented with arm swelling and had either failed to respond to or were unsuitable for endovenous therapy. One patient desired elective removal of a venous stent because of pain and anxiety. Operative procedures were performed at the discretion of the operating surgeon. RESULTS: Fourteen patients (eight men; average age, 42 years) underwent open thoracic outlet decompression with first rib resection (n = 11) or claviculectomy (n = 4). Indication for treatment was dialysis-associated venous outlet obstruction in five, effort thrombosis (Paget-Schroetter syndrome) in seven, presence of a venous implantable cardioverter-defibrillator lead in one, and patent but painful venous stent in situ with significant anxiety. Nine patients required first interspace sternotomy for exposure of the proximal subclavian vein. One patient with acute Paget-Schroetter syndrome had been treated with preoperative thrombolysis without resolution; all others were chronically occluded. Bypass conduit was jugular vein in one, bovine carotid artery graft in two, paneled great saphenous vein in two, femoral vein in eight, and polytetrafluoroethylene in one. Mean operative time was 187 (±45) minutes, with mean estimated blood loss of 379 (±209) mL. There were two early graft thromboses that were revised with jugular venous turndown and femoral vein bypass, respectively. All patients experienced immediate symptom relief. Morbidity included two graft thromboses, two instances of wound dehiscence, two operative site hematomas, non-ST elevation myocardial infarction, vein harvest site infection, polytetrafluoroethylene graft infection, and phrenic nerve injury. At a mean follow-up of 357 (±303) days, primary assisted patency and secondary patency for the entire cohort were 71.4% and 85.7%, respectively, with 100% primary assisted patency among those with femoral vein conduit. At last follow-up, 13 of the 14 living patients (93%) remained symptom free. CONCLUSIONS: In our experience, venous bypass combined with thoracic outlet decompression achieves symptomatic relief in approximately 90% of patients with symptomatic upper extremity central venous occlusion, with morbidity limited to the perioperative period.