Percutaneous venous stenting for thoracic outlet syndrome

The thoracic outlet syndrome (TOS) is manifested by symptoms of venous compression or thrombosis in approximately 4% of the time, Even with early recognition and aggressive anticoagulant therapy about 25% of patients continue to complain of residual disability. Historically failure to restore venous patency in TOS was due to incomplete understanding of the pathology and therefore incomplete management. Thrombectomy or thrombolytic therapy is often inadequate unless the underlying etiology is corrected. Chronic venous compression results in scarring, not relieved by widening the outlet via rib resection, scalenectomy or abnormal band lysis. The authors describe a twenty-seven-year-old woman who underwent successful subclavian and axillary vein thrombolysis with urokinase but remained symptomatic. Persistent subclavian venous stenosis was confirmed by sonography and angiography. Transaxillary first rib resection was performed with no relief of stenosis. Percutaneous transbrachial angioplasty with stent placement across the stenotic area resulted in complete sonographic, angiographic and symptomatic relief. One year later she remains asymptomatic. Subclavian venous patency is confirmed sonographically. The combination of clot lysis, external decompression and internal widening is crucial. If internal stenting results in long term patency then these three modalities may afford an expeditious, durable and cosmetically acceptable therapy for this frustrating disorder.