Does the anticoagulation regimen change for a patient with venous Thoracic Outlet Syndrome (TOS) undergoing surgery?

Anticoagulation Management for Venous Thoracic Outlet Syndrome (VTOS) Undergoing Surgery

For patients with venous thoracic outlet syndrome (VTOS) undergoing surgery, the anticoagulation regimen should follow the same intensity and duration as standard upper extremity deep vein thrombosis (UEDVT) protocols, with a minimum of 3 months of anticoagulation therapy. 1

Initial Anticoagulation Management

• For acute VTOS involving the axillary or more proximal veins, parenteral anticoagulation with LMWH or fondaparinux is recommended over IV or SC unfractionated heparin 1
• Direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, edoxaban, or dabigatran are preferred over vitamin K antagonists (VKAs) for the treatment phase (first 3 months) 1
• For patients undergoing thrombolysis for VTOS, the same intensity and duration of anticoagulation is recommended as for those not undergoing thrombolysis 1

Duration of Anticoagulation for VTOS Patients

• A minimum duration of 3 months of anticoagulation is suggested for VTOS involving the axillary or more proximal veins 1
• For VTOS not associated with a central venous catheter or cancer, 3 months of anticoagulation is recommended over a longer duration of therapy 1
• For VTOS associated with a central venous catheter that is removed, 3 months of anticoagulation is recommended in patients without cancer 1

Special Considerations for VTOS Surgery

• If thoracic outlet decompression surgery is performed, anticoagulation should still be maintained for at least 3 months 1
• Persistent thoracic outlet syndrome is considered a continuing risk factor that may warrant extended anticoagulation beyond the initial 3 months 1
• For patients with severe post-thrombotic syndrome following VTOS, extended anticoagulation should be considered 1

Perioperative Anticoagulation Management

• For patients on anticoagulation who require thoracic outlet decompression surgery, follow standard perioperative anticoagulation protocols based on thromboembolism risk 1
• For high-risk thromboembolism patients (recent VTE within 3 months), bridging with heparin may be considered 1
• For low-to-moderate risk patients, bridging with heparin is generally not recommended 1

Post-Surgical Considerations

• After surgical decompression for VTOS, anticoagulation should be resumed promptly when hemostasis is assured 1
• For patients with residual venous stenosis after surgical decompression, balloon angioplasty may be performed, but the anticoagulation regimen remains unchanged 2
• Compression bandages or sleeves may be used for post-thrombotic syndrome symptoms in addition to anticoagulation 1

Long-Term Management

• If extended anticoagulation is needed beyond 3 months due to persistent thoracic outlet syndrome, reduced-dose DOACs (apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily) are suggested over full-dose regimens 1
• Patients on extended anticoagulation should be reassessed at least annually for continued necessity, bleeding risk, and any changes in health status 1
• Surgical intervention (first rib resection) for severe thoracic outlet syndrome may eliminate the need for continued anticoagulation if the anatomical cause is fully addressed 1

The anticoagulation approach for VTOS should be guided by the same principles as other upper extremity DVTs, with the recognition that the underlying anatomical compression may represent a persistent risk factor requiring surgical correction to prevent recurrence 3, 4.