Management of Venous Thoracic Outlet Syndrome

SCV effort thrombosis due to venous TOS occurs in young, active, healthy individuals and is responsible for the spontaneous onset of substantial upper extremity swelling, cyanosis, and discomfort. Effective treatment of venous TOS involves a comprehensive strategy founded on prompt diagnosis based on clinical suspicion, anticoagulation, early venography and catheter-directed thrombolysis, and interval thoracic outlet decompression. Although surgical treatment based on either transaxillary or infraclavicular thoracic outlet decompression may be used quite successfully for many patients, the paraclavicular approach combines the advantages of the supraclavicular exposure used for neurogenic and arterial forms of TOS, with an infraclavicular exposure that permits complete resection of the medial first rib, wide exposure of the SCV, and direct vascular reconstruction when needed in the same operative setting. In the authors' experience, using this approach, they have been able to offer definitive surgical treatment to virtually all patients with symptomatic venous TOS or recent effort thrombosis, regardless of the interval between initial diagnosis and referral, previous treatment, or adverse findings on contrast venography. This has produced excellent results, with low rates of persistent or recurrent vein obstruction, freedom from the need for long-term anticoagulation, and a typical return to unrestricted physical activity within 12 weeks of operative management. These results have led to the conclusion that operative procedures based on paraclavicular exposure provide the most versatile, comprehensive, and safe approach to the treatment of venous TOS.