Timing of Thoracic Outlet Decompression after Thrombolysis for Primary Upper Extremity Deep Venous Thrombosis: A Systematic Review

Background: The optimal timing of decompression surgery after thrombolysis in patients with primary upper extremity deep vein thrombosis (UEDVT) is still a matter of debate. This system- atic review compares the safety and efficacy of early intervention versus postponed intervention in patients with primary UEDVT. Methods: A structured PUBMED, EMBASE, and COCHRANE search was performed for studies reporting on the timing of surgical intervention for primary UEDVT. Studies reporting on timing of decompression surgery in combination with recurrent thrombosis, bleeding complications, and symptom-free survival were included. Two treatment groups were defined; group A received surgical decompression within two weeks after thrombolysis and group B after two weeks or more. All end points were assessed in accordance with the reported outcomes in the included articles. Mean percentages were calculated using descriptive statistics. Results: Six articles (126 patients) were included: 87 patients in group A versus 39 in group B. In group A, bleeding complications occurred in 7% of patients versus 5% in group B. Two-third of the bleeding complications in group A occurred in patients receiving surgical decompression within 24 hr after thrombolysis while kept on intravenous heparin both preoperatively and post- operatively. Reported preoperative recurrent thrombosis was 7% in group A versus 11% in group B, another 13% had postoperative recurrent thrombosis versus 21% in group B. The effectiveness of both treatment strategies was comparable with a total of 89% of patients in group A with minimal or no symptoms at final follow-up compared with 90% in group B. The mean follow-up in group A was 35 months (1-168 months) and 28 months (1-168 months) in group B. Conclusions: Based on the limited available data presented in this review, early decompres- sion surgery within two weeks after catheter-directed thrombolysis seems as safe and effective as postponed surgical intervention in patients with primary UEDVT.