From the Guidelines
Management of venous thoracic outlet syndrome (vTOS) requires a multidisciplinary approach combining medical therapy, thrombolysis, and surgical intervention, with the most recent and highest quality study 1 guiding the treatment approach. The initial treatment involves anticoagulation with heparin (either unfractionated at 80 units/kg bolus followed by 18 units/kg/hr infusion, or low molecular weight heparin like enoxaparin 1 mg/kg twice daily) to prevent clot propagation, as recommended by the study 1. Following anticoagulation, catheter-directed thrombolysis is considered if the patient presents within 14 days of symptom onset, with tissue plasminogen activator (tPA) at 0.5-1 mg/hr for 24-48 hours being a common regimen, as discussed in the study 1. After clot dissolution, definitive treatment requires surgical decompression, usually through first rib resection and scalenectomy, ideally performed within 2 weeks of thrombolysis, as outlined in the study 1. Postoperatively, patients should continue anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants for 3-6 months, as recommended by the study 1. Some key points to consider in the management of vTOS include:
- The use of imaging studies such as venography 1, MRI 1, and CTV 1 to evaluate the extent of venous compression and thrombosis
- The role of thrombolytic agents in the treatment of vTOS, as discussed in the study 1
- The importance of physical therapy and compression stockings in the prevention of recurrence and management of post-thrombotic syndrome symptoms, as highlighted in the example answer. Overall, the management of vTOS requires a comprehensive approach that addresses both the acute thrombosis and the underlying anatomical compression, with the goal of preventing recurrence and improving quality of life, as emphasized by the study 1.
From the Research
Management of Venous Thoracic Outlet Syndrome (TOS)
The management of venous thoracic outlet syndrome (VTOS) involves a combination of diagnostic evaluation, treatment, and surgical intervention.
- Clinical evaluation includes a history and physical examination followed by catheter-based venography for definitive confirmation of the diagnosis and initial treatment with pharmacomechanical thrombolysis 2.
- After restoration of subclavian vein (SCV) patency, patients are maintained with anticoagulation and surgical therapy is usually planned within 4 to 6 weeks 2.
- Surgical management of VTOS can be accomplished via different protocols involving either the transaxillary, infraclavicular, or paraclavicular approaches to thoracic outlet decompression 2, 3, 4.
Surgical Approaches
- The paraclavicular approach allows for complete thoracic outlet decompression and definitive management of the damaged SCV in one operative setting 2.
- The infraclavicular approach has been adopted as a safe and efficacious treatment of VTOS, with low perioperative morbidity and good patency rates 3, 4.
- The transaxillary approach is also used, although less commonly 3.
Postoperative Care
- After surgical therapy, interval anticoagulation and a comprehensive physical therapy and rehabilitation program are important in achieving a return to full function 2.
- Patients are typically seen postoperatively at 1-month and 6-month intervals, or for any new or recurrent symptoms 3.
Alternative Treatments
- Direct oral anticoagulants may be used in patients with upper extremities deep vein thrombosis due to VTOS who refuse endovascular approach or surgery 5.
- Conservative management of thoracic outlet syndrome requires accurate evaluation of the peripheral nervous system, posture, and the cervico-scapular muscles, and may include postural correction, stretching exercises, and strengthening exercises 6.