Need for emergency treatment in subclavian vein effort thrombosis

Background: Effort thrombosis of the subclavian vein is often inadequately treated - and most of the time treatment is late. Physicians are unfamiliar with this syndrome and its treatment. Study design: In 65 patients with this syndrome, three major categories were recognized. The acute group (less than one week) comprised 14 patients subdivided into first time occurrence, recurrent episode, or occurrence after previous surgery for thoracic outlet. The subacute group (between one and two weeks) comprised four patients with the same subdivisions as the acute group. The chronic group (greater than two weeks) comprised 47 patients. Acute and subacute cases were treated with direct lytic therapy (urokinase) followed by operation. An anterior subclavicular approach was used to remove the first rib, subclavius, and anterior scalene muscles and to have safe access to the vein. Patients in the chronic stage required vein patch angioplasty of the strictured segment. Results: In acute cases (first time occurrence) decompression of the vein only at the thoracic outlet was effective in 100 percent of cases (eight patients). Vein patch angioplasty was needed in recurrent, subacute, and chronic cases. This procedure was 100 percent effective if stenosis was less than 2 cm long. Longer-segment obstructions had only a 37.5 percent (three of eight) success rate. Fourteen patients were considered inoperable. Conclusions: It is recommended that effort thrombosis of the subclavian vein be treated acutely with thrombolytic agents followed by operation. This aims to prevent chronic fibrous obliteration of the subclavian vein, which is a consistent complication in patients who have had delayed treatment for more than two weeks. If operable, chronic stage patients always require vein patch angioplasty.