Outcomes following interval delayed first rib resection for acute axillosubclavian deep venous thrombosis.

BACKGROUND: Current management of axillosubclavian deep venous thrombosis (DVT) often uses thrombolysis for the DVT, prompt first rib removal, and occasional venoplasty or stenting. Our institution has increasingly used anticoagulation alone followed by interval first rib resection. We sought to analyze the effectiveness of this simplified technique. METHODS: Between September 2012 and April 2021, 27 patients were identified within the institution's electronic medical record as having undergone first rib resection for upper extremity DVT. Seven of these patients had undergone preoperative thrombolysis before referral and were excluded. Among the remaining 20 patients, preoperative clinic charts were evaluated for age, venous segment involvement, contralateral limb involvement, presence of documented hypercoagulable state, duration of preoperative and postoperative anticoagulation, and postoperative outcomes. RESULTS: Of the 20 patients (mean age, 26.2 years; 13 males) presenting with acute axillosubclavian DVT, all patients had right (n = 8) or left (n = 12) arm swelling. Five patients had extremity pain and four had extremity discoloration. Ten had axillosubclavian vein involvement, 9 had subclavian vein involvement, and 1 had axillary vein involvement. Two patients were on oral contraceptives and no patients had any other diagnosed hypercoagulable conditions. The mean duration of preoperative and postoperative anticoagulation was 3.2 ± 2.6 months and 2.1 ± 2.1 months, respectively. Nineteen patients underwent supraclavicular first rib resection and 1 patient underwent transaxillary resection. Twelve patients (60%) demonstrated complete DVT resolution by venous duplex examination during the postoperative period and 8 patients (40%) demonstrated partial recanalization/chronic DVT. Complications included one hemothorax and one thoracic duct injury. All 20 patients remain asymptomatic without arm swelling, with a mean follow-up of 55.1 ± 34.7 months. CONCLUSIONS: Among patients presenting with acute axillosubclavian DVT, anticoagulation alone followed by interval first rib resection proved to be successful in providing symptomatic relief in the short to medium term. By eliminating the need for preoperative thrombolysis and postoperative venograms, this potentially cost-saving algorithm simplifies our management for acute venous thoracic outlet syndrome while maintaining good clinical outcomes. Because this study only analyzed our management algorithm's effectiveness in the short to medium term, the long-term effectiveness of this treatment will need to be demonstrated.

Duplex Scans Performed Immediately Following Lower Extremity Angioplasty and Stenting are of Limited Utility.

BACKGROUND: Together with clinical examination, surveillance duplex examination represents the Society of Vascular Surgery recommendations for follow-up after endovascular intervention on the superficial femoral artery (SFA) and popliteal arterial segments. Compliance with postprocedural follow-up remains challenging. To establish a postangioplasty physiologic baseline, our institution began obtaining immediate postprocedural surveillance studies following lower extremity arterial interventions. We reviewed the utility of immediate postprocedural surveillance to determine if these studies enhanced postoperative care. METHODS: Serial patients undergoing SFA and popliteal angioplasty and stenting from January 2014 to December 2020 were identified from our prospectively maintained Vascular Surgery database. Patient demographic information, procedural details, and procedural outcomes were subsequently analyzed from the electronic medical record. RESULTS: Two hundred and sixty-three patients underwent 385 SFA and/or popliteal angioplasty/stenting interventions. Mean patient age was 64.8 ± 10 years. Among these 385 procedures, 350 (90.9%) were followed by immediate (<4 hours) postprocedural lower extremity arterial duplex scans. These 350 procedures included percutaneous transluminal angioplasty and/or stenting of the SFA (n = 236), popliteal artery (n = 34), or both (n = 80). Of these studies, 25 results (7.1%) were abnormal. One asymptomatic patient was admitted to hospital for immediate thrombolysis; however, the remaining 24 patients were followed clinically with no immediate intervention required. Abnormal results included 13 abnormalities appreciated on the final angiogram with 9 patients with known occlusions or stenoses, and 4 patients with mild to moderate CFA stenosis. Abnormal findings not detected on the final angiogram included 7 patients with mild to moderate stenosis and 5 patients with short occlusions (1.4%). All 5 patients with short segmental occlusions not detected on final arteriogram had preprocedural anatomy classified as either TASC C (TransAtlantic Inter-Society Consensus: SFA occlusions > 15 cm in length, n = 1) or TASC D (SFA occlusions > 20 cm in lenth, n = 4). CONCLUSIONS: Immediate postprocedural duplex scans demonstrate significant vessel stenosis or occlusion in approximately 7% of cases but most stenoses and occlusions were noted on final arteriography. Duplex detected short segmental occlusions not noted on final arteriography were rare (1.4%), and occurred among patients with TASC C or TASC D occlusive disease. These duplex detected abnormalities rarely changed the patient's immediate plan of care. The performance of these immediate postprocedural duplex scans demonstrated limited clinical utility.

Safety of Utilizing Ultrasound as the Sole Modality of Follow-Up after Endovascular Aneurysm Repair.

BACKGROUND: Post endovascular aneurysm repair (EVAR), surveillance with computed tomography-aortography (CTA) remains the most common practice, per Society for Vascular Surgery (SVS) guidelines. Chronic exposure to both radiation and intravenous (IV) contrast has raised concerns about long-term CTA follow-up (FU). As we have selectively used ultrasound (US) as a sole modality for post-EVAR surveillance, we sought to review our outcomes in this subset of patients. METHODS: Retrospective review of our institution's vascular database identified 213 EVAR patients from 2013 to 2021. Fenestrated-EVAR and snorkel reconstructions were excluded. Patient demographics/outcomes, abdominal aortic aneurysm (AAA) characteristics, and FU modalities and outcomes were analyzed. Unpaired Student's t-test, ANOVA, and chi-squared test were used to assess group differences. RESULTS: Eighty-five of the 213 EVAR patients (39.9%) were lost to FU within 3 months. Among the 128 remaining patients, 91 underwent FU using initial US, while 37 patients underwent post-EVAR FU initially using CTA. There were no significant differences (P > 0.05) between patient age (75.5 ± 9.4 vs. 75.3 ± 8.5), body mass index (BMI) (27.7 ± 5.4 vs. 28.9 ± 7.4), or mean AAA size (5.6 ± 1.1 vs. 5.9 ± 1.2) in US-surveilled and computed tomography (CT)-surveilled groups, respectively. Of the 91 patients, initially surveilled with US, 15 patients demonstrated endoleak and/or AAA growth (>5 mm). The 15 patients with US-demonstrated endoleak and/or growth underwent confirmatory CTA, with 3 patients eventually requiring EVAR revision. Among 37 patients initially surveilled with CT, 10 demonstrated significant growth and 2 patients eventually required EVAR revision. There were no patients with AAA rupture during post-EVAR surveillance. FU data were analyzed among a select lower-risk group of patients (preoperative AAA diameter ≤5.5 cm, BMI ≤30, and no endoleak at completion of EVAR). Among this group, there were no surveilled patients who required EVAR reintervention, regardless of surveillance modality (US n = 32; CT n = 4). The average FU was 29.5 ± 26.4 months in the US group and 26.4 ± 22.3 months in the CT group (P > 0.05). CONCLUSIONS: Although initial CT surveillance following EVAR remains ideal, in select lower-risk patients, US is a viable alternative even for the initial post-procedure study. Advantages include decreased radiation exposure and cost. Our data suggest that US is a safe sole modality for surveillance following EVAR in selective patients.