July 14, 2004

New Approach To the Treatment Of Subclavian Vein Effort Thrombosis

Rafal Barczak¹, Eric G. Lowe¹, Fernando Lamounier², David Shapiro², Kathleen Greene³, Robert Lowe^3
1University of Connecticut School of Medicine, Farmington, CT;²Hartford Hospital, Hartford, CT;³Connecticut Vascular Institute, Hartford, CT

Objective: Since 2001, we have treated patients with subclavian vein effort thrombosis (SVET) with initial lysis followed by infraclavicular trans-sternal first rib resection and endarterectomy and saphenous patch venoplasty of the subclavian vein. Post-operative warfarin anticoagulation was maintained for three months then discontinued if duplex studies were normal. We present follow-up of this new approach.

Methods: Eighteen patients (11 male, 7 female) with SVET were treated by the principal author over three years. The hospital course was evaluated by retrospective chart review. Objective data on vein patency were obtained by detailed duplex evaluation during April 2004. Each patient's subjective evaluation of this approach was obtained by a detailed questionnaire administered during the same visit.

Results: Mean age was 40.3 years (range 17-63), and mean follow-up was 24 months (range 3-39). Mean post-operative stay was 5.2 days. 100% of subclavian veins showed intralumenal residual post-lytic pathology at exploration. Estimated mean operative blood loss was 465ml (range 200-1200), mean post-operative drain output was 430ml (range 0-1290), and 28% of patients required blood product transfusions. All patients had patent initial duplex studies at three months and warfarin was discontinued. There was no perioperative mortality; one patient died of MI one year post-operatively. Of the 17 remaining, 15 returned for duplex evaluation and 16 completed the questionnaire. Duplex exam was totally normal in the resting position, with 90 and 120 degrees of elevation, and with military maneuver in 93% of patients. The exam was abnormal only with 120 degrees of elevation in the remaining patient. Questionnaire results showed 81% considered their arm to have normal function; the remainder considered their arm slightly limited in function.

Conclusions: This approach is an effective treatment for SVET. In addition to restoring normal vein patency and arm function, it allows withdrawal of anticoagulation after three months.