Primary subclavian-axillary vein thrombosis: the relative roles of thrombolysis, percutaneous angioplasty, stents, and surgery.

This article is based on a review of the literature and a survey of vascular surgeons augmented by more recent reports of new therapeutic approaches. Primary subclavian-axillary vein thrombosis (SAVT) occurs mostly (approximately 70%) in the dominant upper extremity of active healthy patients after a period of unusual exercise or arm positioning. In such patients, most experience severe symptoms, and this outlook is not modified by anticoagulant therapy. These patients should be considered for interventional therapy, beginning with catheter-directed thrombolysis. Although it is clear that the initial management of primary SAVT, by catheter-directed thrombolysis, followed by surgical relief of phlebographically demonstrated extrinsic thoracic outlet compression, is well accepted, the preferred method of dealing with residual intrinsic stenoses and occlusions is still controversial. The durability of percutaneous transluminal angioplasty (PTA) or stents still needs to be defined by long-term follow-up, but kinking or compression of the stent has lead to failure when performed without concomitant thoracic outlet (TO) decompression. Thus, in addition to thrombolysis and TO decompression, residual intrinsic stenoses can be treated either by stenting or by surgical reconstruction, the latter preferably through an extended incision that avoids claviculectomy. Surgical reconstructions are favored only for short, proximal occlusions or for residual stenoses, when performed at the same time as thoracic outlet decompression. First rib removal has lost its popularity in the treatment of postthrombotic occlusion of the subclavian-axillary venous segment and should not be used alone in this setting in the absence of objective proof of positional collateral obstruction.