Vascular Surgeon, George Geroulakos
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Subclavian vein thrombosis

1% to 4% of all deep vein thrombosis occurs in the upper extremity and approximately a quarter of all upper extremity thrombosis are primary. Untreated patients with subclavian vein thrombosis could experience symptoms of chronic disability with swelling, pain and weakness caused by early exercise fatigue. Many patients with these symptoms are young and active and their lifestyle is significantly affected. It is now considered that the optimal management of primary subclavian vein thrombosis requires restoration of luminal patency with thrombolysis and the removal of any external compression (first rib resection).

Surgery in the thoracic outlet is not without the potential of serious complications such as injury to the brachial plexus causing paralysis or chronic pain syndromes, subclavian artery/vein injury causing major bleeding. The timing and indications for thoracic outlet decompression in patients with primary axillary/subclavian vein thrombosis are not well defined.

Surgical therapy for subclavian vein thrombosis is still evolving and is currently based on the experience derived from small institutional series. There are no randomised controlled trials and there only very occasional small series using disease specific quality of life questionnaires to assess the functional result of surgical interventions. However from the available evidence the following recommendations can be made: Patients can be assessed one month following thrombolysis while they still receive anticoagulation. Asymptomatic patients with fully recanalised vein and no positional narrowing of the subclavian vein need no surgical decompression of the thoracic outlet. Symptomatic patients with recanalised veins and positional obstruction of their subclavian vein will benefit from first rib resection. Patients with chronically occluded subclavian vein should not be routinely considered for first rib resection. For these patients an individual approach is appropriate and starting from the least invasive approach is justified.



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