Thoracic outlet syndrome and upper extremity thrombosis
Patients with deep vein thrombosis of the upper extremities often require first rib resection after successful restoration of the vessel lumen. This intervention is justified in confirmed thoracic outlet syndrome.
In surgical practice, three main approaches are distinguished: supraclavicular, infraclavicular, and axillary.
- Axillary approach provides an excellent cosmetic result and good exposure of the costoclavicular space in the compression zone. However, it is not suitable for extensive venous reconstructions and carries a risk of injury to the long thoracic nerve.
- Infraclavicular approach is ideal for working with the rib and vein. It minimally affects structures not involved in the pathological process (phrenic nerve, brachial plexus, artery) and allows for intraoperative phlebography since the patient lies supine.
Subclavian vein stenting is strictly not recommended as an alternative to open surgery. Stent placement is advisable only for severe, refractory stenoses persisting after surgical decompression.
Catheter-related thrombosis
Venous catheter placement is a frequent trigger for thrombosis. The pathogenesis of this condition is based on four factors:
- Direct mechanical trauma to the vessel wall at the time of instrument insertion.
- Local or systemic hypercoagulation as the body's response to trauma.
- Venous stasis (slowed blood flow).
- The physical presence of the catheter acting as a foreign body within the vessel lumen.
Pulmonary embolism (PE)
The main source of PE is deep vein thrombosis (DVT). Therefore, lower extremity venous ultrasound is the primary diagnostic step. The detection of proximal thrombosis indirectly confirms embolism and serves as a strong rationale for initiating anticoagulant therapy. To assess right ventricular dysfunction and search for floating cardiac thrombi, echocardiography is used.
Management tactics depend on the clinical presentation:
- For arterial hypotension, infusions and vasopressors are indicated.
- For hypoxemia, oxygen therapy is indicated.
- To prevent recurrences, heparin sodium is prescribed.
- For the prevention of venous thrombosis (e.g., in orthopedics), fondaparinux sodium is administered subcutaneously.
For acute massive PE, intravenous thrombolysis is indicated (urokinase, streptokinase, tissue plasminogen activator preparations), although it carries a high risk of hemorrhagic complications. If a mobile (floating) thrombus is detected in a main vein, surgical prophylaxis is employed: a vena cava filter is implanted, or inferior vena cava plication is performed.
A long-term complication can be chronic thromboembolic pulmonary hypertension (CTEPH). It is treated using bilateral pulmonary endarterectomy under deep hypothermic circulatory arrest. Age and high vascular resistance are not absolute contraindications to the surgery.
Diagnostic features in pregnant women
In pregnant patients, the diagnosis of venous thrombosis is based on safe non-ionizing methods: duplex or triplex venous scanning and MR venography. If clinical symptoms of DVT are present and the initial ultrasound is negative, the study must be repeated.
Radiation-exposure methods (CT pulmonary angiography, scintigraphy) are used exclusively to confirm PE when ultrasound is negative. Using X-ray methods merely to assess a proximal thrombus segment is strictly discouraged, as it does not alter management tactics. Radiation methods to evaluate pelvic or leg veins are justified only in critical situations: under threat of limb loss (for thrombolysis), the need for vena cava filter placement, or MRI unavailability.
The decision on hospitalization of a pregnant woman is made by the hospital surgeon or cardiovascular surgeon.
Virchow's triad (wall injury, stasis, hypercoagulation) + foreign body = classical pathogenesis of catheter-related thrombosis.
Class and exam questions
Can first rib resection be replaced by stenting in thoracic outlet syndrome?
No, endovascular intervention is not an alternative to open decompression. Stenting is used only if pronounced venous stenosis persists even after rib resection.
How to treat chronic pulmonary hypertension following a PE?
The primary method is bilateral pulmonary endarterectomy. The procedure is performed under deep hypothermia and complete circulatory arrest.
What to do if a pregnant woman has symptoms of thrombosis, but the initial ultrasound showed nothing?
It is necessary to perform a repeat ultrasound scan of the lower extremity veins. If PE is suspected and venous ultrasound is negative, advanced lung imaging methods should be pursued.
What else to study on this topic
- Indications and risks of thrombolytic therapy in acute massive PE
- Technique of inferior vena cava plication and vena cava filter placement
- Application of fondaparinux sodium in orthopedic surgery
- Multidisciplinary approach to operability assessment in CTEPH
- The role of MR venography in diagnosing isolated pelvic vein thrombosis
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