Long-Term Results of Local Thrombolysis Followed by First Rib Resection: An Encouraging Clinical Experience in Treatment of Subclavian Vein Thrombosis

Abstract

The purpose of this study was to present the long-term results of our experience, which includes thrombolysis, surgical decompression, and long-term anticoagulation. The medical records of 24 patients who were admitted to Academic Hospital Vrije Universiteit, Amsterdam, the Netherlands, between January 1983 and October 1997, with effort thrombosis of the subclavian vein were reviewed. There were 21 men and 3 women, with a mean age of 30.5 years and an average duration of the symptoms of 2.9 days. Clinical diagnosis was confirmed by phlebography and duplex in all patients. A loading dose of 10,000 units streptokinase was given followed by an infusion at a rate of 10,000 units per hour. Phlebography was repeated daily in order to evaluate the effect of the treatment. Thrombolysis was achieved in 2 to 8 days (mean 5 days). After achievement of complete thrombolysis, anticoagulation with heparin and coumarin derivatives was started; the latter were continued for 3 months. Six to 12 weeks after the thrombolysis, patients with costoclavicular compression syndrome underwent surgery. A transaxillary first rib resection, partial scalenotomy, and transection of the tendon of subclavian muscle were performed. Thrombolysis was achieved in all patients but one, with a successful lysis percentage of 95.8%. In one patient, the local streptokinase therapy had to be discontinued because of pulmonary embolism. Resection of the first rib was performed on 19 patients. Two patients refused to be operated on. The other three were lost to follow-up, right after the thrombolytic therapy. In long-term evaluation, all the patients who underwent first rib resection were symptom free, whereas the two patients who refused to be operated on had pain and discoloration of the affected arm, although venous patency was achieved. The subclavian vein thrombosis occurs as a result of repetitive trauma due to anatomic constriction of the vein by the clavicle and the first rib complex. Therefore, we advise addressing the therapy not only to the superimposed thrombus but also to the correction of the underlying anatomic abnormality.