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Stanford Vascular & Endovascular Surgery

Jason T. LeeUCSF Vascular Symposium 2015

How my current algorithm for venous Thoracic Outlet Syndrome

has evolved

Vascular Surgery

Disclosures

• Nothing to Disclose

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Basic Facts

• 3-80/1000 population in US

• Patient visits– Will see 4.7 physicians prior to diagnosis– Will see 6.7 physicians prior to surgery

• Lack of standardized diagnostic or treatment criteria

Huang et al 2004

Landry et al 2001

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Epidemiology• Analysis of large administrative database to

determine national trends of surgical intervention for Thoracic Outlet Syndrome

– Incidence of operation

– Type of TOS

– Type of Surgeon

– Mortality

– Inpatient complications

– Volume effect

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RESULTSINCIDENCE

Range 1568-3740 cases/year, median 252496% neurogenic3% venous1% arterial

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RESULTSTYPE OF SURGEON

VASCULARTHORACICNEUROSURGEONORTHOPEDIC67%20%

7% 6%

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RESULTSNeurogenic vs. Venous

Neurogenic Venous P-value

Median age decile 30-39 20-29 <0.0001

% female 68.6% 38.4% <0.0001

Hospital stay (days) 2.7 6.7 <0.0001

Mortality 0.04% 1.4% <0.001

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RESULTSComplications

• High Volume Hospital– counted the number of procedures performed by each

hospital each year and assigned the top tercile as high volume

– >15 cases per year associated with lower complication rate

• Odds Ratio 0.43 (p=0.007)

• Teaching status– Equal between teaching and non-teaching hospitals

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Anatomy

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Venous TOS

• Subclavian vein thrombosis– Overuse injury– Hypertrophied scalene– Costoclavicular ligament– Hypercoagulable state

• Presentation– swelling– DVT– Muscle ache/fatigue

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Historical Perspective• 1875 - Paget describes “gouty phlebitis” of UE,

which he attributes to vasospasm• 1884 - Schroetter postulates subclavian/axillary vein

thrombosis as cause• 1949 - Hughes reviews 320 published cases, coins

“Paget-Schroetter syndrome”• 1950s - subclavian vein catheters come into use• 1960s - association of primary SV/AV thrombosis

with exertion recognized, leading to coining of “effort thrombosis”

• 1970s - subclavian vein catheterizations recognized as secondary cause of SV/AV thrombosis

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Development of a treatment paradigm for vTOS

• Simple observation and anticoagulation yields poor results

• Open surgical thrombectomy leads to high incidence of early rethrombosis

• Early thrombolysis is effective as initial strategy– Rapidly restores patency– Confirms anatomy– safe

Donayre et al, Am J Surg 1996Machleder, Sem Vasc Surg 1992Deweese et al, Circulation 1970

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18 yo baseball catcher

Working out on weekend

Swollen R arm

Duplex showed axillo-subclavian occlusion

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Audience participation

A. anticoagulation only

B. thrombolysis then anticoagulation

C. thrombolysis with immediate rib resection

D. thrombolysis, anticoagulation, delayed rib resection 3%

64%

27%

6%

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18 yo baseball catcher

Working out on weekend

Swollen R arm

Duplex showed axillo-subclavian occlusion

Venography

Thrombolysis

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18 yo baseball catcher

Working out on weekend

Swollen R arm

Duplex showed axillo-subclavian occlusion

Venography

Thrombolysis

Mechanical

Chemical

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18 yo baseball catcher

Working out on weekend

Swollen R arm

Duplex showed axillo-subclavian occlusion

Venography

Thrombolysis

Mechanical

Chemical

Balloon venoplasty

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Treatment options

• Immediate surgery

• If surgery, what are the issues?– Approach

– Venoplasty/stent– Venolysis/venous

replacement

• Trial of anticoagulation– Surgery if symptoms

persist

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Immediate Surgery vs. Conservative Approach

• Immediate surgery– Avoid longer regimen of

anticoagulation– Return to baseline activity

sooner

• Conservative– Less inflammation around

vein leading to safer operation

– Allows for possibility of non-operative management

Machleder, J Vasc Surg 1993Angle et al, Ann Vasc Surg 2001Lee et al, J Vasc Surg 2000

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SuspectedPSS

DuplexUltrasound

Venogram &Thrombolysis

Repeat &Observe

-

+

Heparin toWarfarin

Sxs at OneMonth?

First Rib Resection

YesContinue warfarin

No

Sxs at 3Months?

First Rib Resection

Discontinuewarfarin

Yes

No

Stanford Algorithm-CURRENT

Athlete

Young (<28)

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Lots of Choices for patients

• Numerous options for VTOS treatment– Conservative management– Surgery

• Timing• Approach• Adjuncts

• CARE SHOULD BE INDIVIDUALIZED

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Technical Aspects

• Infraclavicular approach

• Vein reconstruction

• Timing of post-op venogram/venoplasty?

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Vascular Surgery Vascular SurgeryCourtesy of J. Ernesto Molina

Vascular SurgeryCourtesy of J. Ernesto Molina

Vascular SurgeryCourtesy of J. Ernesto Molina

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Vascular SurgeryCourtesy of J. Ernesto Molina

Vascular SurgeryCourtesy of J. Ernesto Molina

The Hopkins Algorithm

• Johns Hopkins protocol– Thrombolysis (typically done prior to referral)– Systemic anticoagulation– First rib resection and scalenectomy

• Restart Lovenox POD #3– Two week follow-up venogram (+/- PTA)

• Discontinue Lovenox if vein widely patent– Four week clinic follow up with Duplex exam

• Anticoagulation duration based on symptoms and duplex findings

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Post op Orders

• Resume lovenox POD#3-4

• Schedule venogram POD 7-14– No residual narrowing/no need for venoplasty

• Finish 1 month total anticoagulation

– Need venoplasty• Complete one additional month anticoagulation

• Resume full activity at 6 weeks

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Some questions?

• How about those with subacute or chronic clot or delay in referral to surgery?

• What happens to the athletes?

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27%

33%

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Patient DemographicsAll

n=41nTOSn=27

PSSn=14

Age (mean) 19.0 19.0 18.8

Female (%) 18 (44%) 17 (63%) 1 (7%)

Sport (%)

Swimming 11 (27%) 11 (41%) 0 (0%)

Baseball 13 (33%) 4 (14%) 9 (65%)

Synchronized Swimming 2 (5%) 2 (7%) 0 (0%)

Volleyball 2 (5%) 1 (4%) 1 (7%)

Rowing 4 (10%) 3 (11%) 1 (7%)

Football 1 (2%) 0 (0%) 1 (7%)

Water Polo 5 (12%) 3 (11%) 2 (14%)

Weight Lifting 1 (2%) 1 (4%) 0 (0%)

Wrestling 1 (2%) 1 (4%) 0 (0%)

Diving 1 (2%) 1 (4%) 0 (0%)

Affected side Right (%) 26 (63%) 14 (52%) 12 (86%)

Affected Side Dominant (%) 28 (68%) 16 (59%) 12 (86%)

Bilateral (%) 1 (2%) 1 (4%) 0 (0%)

p=.0007

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Patient DemographicsAll

n=41nTOSn=27

PSSn=14

Age (mean) 19.0 19.0 18.8

Female (%) 18 (44%) 17 (63%) 1 (7%)

Sport (%)

Swimming 11 (27%) 11 (41%) 0 (0%)

Baseball 13 (33%) 4 (14%) 9 (65%)

Synchronized Swimming 2 (5%) 2 (7%) 0 (0%)

Volleyball 2 (5%) 1 (4%) 1 (7%)

Rowing 4 (10%) 3 (11%) 1 (7%)

Football 1 (2%) 0 (0%) 1 (7%)

Water Polo 5 (12%) 3 (11%) 2 (14%)

Weight Lifting 1 (2%) 1 (4%) 0 (0%)

Wrestling 1 (2%) 1 (4%) 0 (0%)

Diving 1 (2%) 1 (4%) 0 (0%)

Affected side Right (%) 26 (63%) 14 (52%) 12 (86%)

Affected Side Dominant (%) 28 (68%) 16 (59%) 12 (86%)

Bilateral (%) 1 (2%) 1 (4%) 0 (0%)

p=.04

p=.18

p = 1

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Treatment Outcomes-PSSAll TOS (n=41)

nTOS(n=27)

PSS(n=14)

Operative 32 (78%) 18 (66.7%) 14 (100%)

Non-Operative 9 (22%) 9 (33.3%) 0 (0%)

Thrombolysis 13 (31.7%) - 13 (92.9%)

Mean timing of Thrombolysis (days prior to surgery, range)

84 (2-730) - 84 (2-730)

Length of Symptoms before Treatment (mean, months)

7.811

(SURG-15.1/ NONOP-3)1.6

Return to Full Sport (%) 35 (85.4%) 22 (81.5%) 13 (92.9%)

Time to Pain Free (mean, months)

2.7 3.4 1.9

Time to Return Full Sport (mean, months)

4.6 4.4 4.7

Average Duration of Post-Op Anti-coagulation (months)

2.3 - 2.3

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Treatment Outcomes-PSSAll TOS (n=41)

nTOS(n=27)

PSS(n=14)

Operative 32 (78%) 18 (66.7%) 14 (100%)

Non-Operative 9 (22%) 9 (33.3%) 0 (0%)

Thrombolysis 13 (31.7%) - 13 (92.9%)

Mean timing of Thrombolysis (days prior to surgery, range)

84 (2-730) - 84 (2-730)

Length of Symptoms before Treatment (mean, months)

7.811

(SURG-15.1/ NONOP-3)1.6

Return to Full Sport (%) 35 (85.4%) 22 (81.5%) 13 (92.9%)

Time to Pain Free (mean, months)

2.7 3.4 1.9

Time to Return Full Sport (mean, months)

4.6 4.4 4.7

Average Duration of Post-Op Anti-coagulation (months)

2.3 - 2.3

• 64% with complete resolution• 36% with partial thrombus

burden

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Treatment Outcomes-PSSAll TOS (n=41)

nTOS(n=27)

PSS(n=14)

Operative 32 (78%) 18 (66.7%) 14 (100%)

Non-Operative 9 (22%) 9 (33.3%) 0 (0%)

Thrombolysis 13 (31.7%) - 13 (92.9%)

Mean timing of Thrombolysis (days prior to surgery, range)

84 (2-730) - 84 (2-730)

Length of Symptoms before Treatment (mean, months)

7.811

(SURG-15.1/ NONOP-3)1.6

Return to Full Sport (%) 35 (85.4%) 22 (81.5%) 13 (92.9%)

Time to Pain Free (mean, months)

2.7 3.4 1.9

Time to Return Full Sport (mean, months)

4.6 4.4 4.7

Average Duration of Post-Op Anti-coagulation (months)

2.3 - 2.3

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Summary• High index of suspicion for TOS patients• Good prognosis for athletes

– 82% nTOS, 93% PSS – full return to sport

• Keys to success:– Multidisciplinary approach to TOS patients

• Sports medicine, orthopedics, physical therapy, team physicians, vascular surgeons, etc.

• Reporting standards and registries upcoming

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Thank You