Paraclavicular Thoracic Outlet Decompression and Venous Reconstruction for Paget-Schroetter Syndrome
Cassra N. Arbabi, Marc Arizmendez, George Berci, Ali Azizzadeh
Cedars-Sinai Medical Center, Los Angeles, CA
OBJECTIVES: Venous thoracic outlet syndrome (vTOS), also known as Paget-Schroetter syndrome or effort thrombosis, results from compression and repetitive injury of the subclavian vein at the costoclavicular ligament. We describe the paraclavicular approach to thoracic outlet decompression and venous reconstruction.
METHODS: A 56 year-old man presented with effort thrombosis of the right axillary and subclavian veins (SCV). He was initially treated with catheter directed thrombolysis which unmasked a SCV stenosis, consistent with vTOS. The patient was offered a right paraclavicular thoracic outlet decompression and venous reconstruction. A 1080p HD compact video microscope (VITOM ®; Karl Storz Endoscopy) was used for videography.
RESULTS: Through a supraclavicular incision, we developed superior and inferior platysmal flaps. The lateral head of the sternocleidomastoid (SCM) was divided and the scalene fat pad was mobilized laterally. The anterior scalene muscle was encircled with a Penrose drain and sharply resected, with care to protect the phrenic nerve anteriorly and the subclavian artery posteriorly. A brachial plexus neurolysis was performed. The middle scalene muscle was then resected with care to protect the long thoracic nerve. The first intercostal muscles were divided sharply from the first rib. An infraclavicular incision was made to dissect the anterior portion of the first rib. The first rib was divided anteriorly near at the sternum and posteriorly at the transverse process of the spine. We then performed circumferential venolysis of the SCV and exposed the confluence of the innominate vein. After proximal and distal control, a vein patch angioplasty was done using a running 6-0 polypropylene. Seprafilm ® (Baxter International Inc) was placed to prevent subsequent scar formation. A tube thoracostomy was placed. The lateral head of the SCM was reapproximated and the wound was closed in standard fashion.
CONCLUSIONS: The post-operative course was uneventful, and the patient was discharged home with oral anticoagulation on day three. The paraclavicular approach to vTOS provides excellent operative exposure for the surgeon and trainees, allowing for radical excision of the anterior and middle scalene muscles, brachial plexus neurolysis, complete 1st rib resection, and SCV reconstruction.
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