Disclosures How my current algorithm for venous Nothing to - - PowerPoint PPT Presentation

▶
disclosures
SMART_READER_LITE
LIVE PREVIEW

Disclosures How my current algorithm for venous Nothing to - - PowerPoint PPT Presentation

Oct 29, 2022 224 likes •350 views

Disclosures How my current algorithm for venous Nothing to Disclose Thoracic Outlet Syndrome has evolved Jason T. Lee UCSF Vascular Symposium 2015 Stanford Vascular & Endovascular Surgery Vascular Surgery Basic Facts 3-80/1000

slide-1
SLIDE 1

1

Stanford Vascular & Endovascular Surgery

Jason T. Lee UCSF Vascular Symposium 2015

How my current algorithm for venous Thoracic Outlet Syndrome has evolved

Vascular Surgery

Disclosures

  • Nothing to Disclose

Vascular Surgery Vascular Surgery

Basic Facts

  • 3-80/1000 population in US
  • Patient visits

– Will see 4.7 physicians prior to diagnosis – Will see 6.7 physicians prior to surgery

  • Lack of standardized diagnostic or

treatment criteria

Huang et al 2004 Landry et al 2001

slide-2
SLIDE 2

2

Vascular Surgery

Epidemiology

  • Analysis of large administrative database to

determine national trends of surgical intervention for Thoracic Outlet Syndrome

– Incidence of operation – Type of TOS – Type of Surgeon – Mortality – Inpatient complications – Volume effect

Vascular Surgery

RESULTS

INCIDENCE

Range 1568-3740 cases/year, median 2524 96% neurogenic 3% venous 1% arterial

Vascular Surgery

RESULTS

TYPE OF SURGEON

VASCULAR THORACIC NEUROSURGEON ORTHOPEDIC

67% 20% 7% 6%

Vascular Surgery

RESULTS

Neurogenic vs. Venous

Neurogenic Venous P-value Median age decile 30-39 20-29 <0.0001 % female 68.6% 38.4% <0.0001 Hospital stay (days) 2.7 6.7 <0.0001 Mortality 0.04% 1.4% <0.001

slide-3
SLIDE 3

3

Vascular Surgery

RESULTS

Complications

  • High Volume Hospital

– counted the number of procedures performed by each hospital each year and assigned the top tercile as high volume – >15 cases per year associated with lower complication rate

  • Odds Ratio 0.43 (p=0.007)
  • Teaching status

– Equal between teaching and non-teaching hospitals

Vascular Surgery

Anatomy

Vascular Surgery

Venous TOS

  • Subclavian vein thrombosis

– Overuse injury – Hypertrophied scalene – Costoclavicular ligament – Hypercoagulable state

  • Presentation

– swelling – DVT – Muscle ache/fatigue

Vascular Surgery

Historical Perspective

  • 1875 - Paget describes “gouty phlebitis” of UE,

which he attributes to vasospasm

  • 1884 - Schroetter postulates subclavian/axillary vein

thrombosis as cause

  • 1949 - Hughes reviews 320 published cases, coins

“Paget-Schroetter syndrome”

  • 1950s - subclavian vein catheters come into use
  • 1960s - association of primary SV/AV thrombosis

with exertion recognized, leading to coining of “effort thrombosis”

  • 1970s - subclavian vein catheterizations recognized

as secondary cause of SV/AV thrombosis

slide-4
SLIDE 4

4

Vascular Surgery

Development of a treatment paradigm for vTOS

  • Simple observation and anticoagulation yields

poor results

  • Open surgical thrombectomy leads to high

incidence of early rethrombosis

  • Early thrombolysis is effective as initial strategy

– Rapidly restores patency – Confirms anatomy – safe

Donayre et al, Am J Surg 1996 Machleder, Sem Vasc Surg 1992 Deweese et al, Circulation 1970

Vascular Surgery

18 yo baseball catcher Working out on weekend Swollen R arm Duplex showed axillo- subclavian occlusion

Vascular Surgery

Audience participation

  • A. anticoagulation only
  • B. thrombolysis then anticoagulation
  • C. thrombolysis with immediate rib

resection

  • D. thrombolysis, anticoagulation,

delayed rib resection

3% 64% 27% 6%

Vascular Surgery

18 yo baseball catcher Working out on weekend Swollen R arm Duplex showed axillo- subclavian occlusion Venography Thrombolysis

slide-5
SLIDE 5

5

Vascular Surgery

18 yo baseball catcher Working out on weekend Swollen R arm Duplex showed axillo- subclavian occlusion Venography Thrombolysis Mechanical Chemical

Vascular Surgery

18 yo baseball catcher Working out on weekend Swollen R arm Duplex showed axillo- subclavian occlusion Venography Thrombolysis Mechanical Chemical Balloon venoplasty

Vascular Surgery

Treatment options

  • Immediate surgery
  • If surgery, what are

the issues?

– Approach – Venoplasty/stent – Venolysis/venous replacement

  • Trial of

anticoagulation

– Surgery if symptoms persist

Vascular Surgery

Immediate Surgery vs. Conservative Approach

  • Immediate surgery

– Avoid longer regimen of anticoagulation – Return to baseline activity sooner

  • Conservative

– Less inflammation around vein leading to safer

  • peration

– Allows for possibility of non-operative management

Machleder, J Vasc Surg 1993 Angle et al, Ann Vasc Surg 2001 Lee et al, J Vasc Surg 2000

slide-6
SLIDE 6

6

Vascular Surgery Vascular Surgery Vascular Surgery Vascular Surgery Suspected PSS

Duplex Ultrasound Venogram & Thrombolysis Repeat & Observe

  • +

Heparin to Warfarin

Sxs at One Month?

First Rib Resection

Yes

Continue warfarin

No

Sxs at 3 Months?

First Rib Resection Discontinue warfarin

Yes No

Stanford Algorithm-CURRENT

Athlete Young (<28)

slide-7
SLIDE 7

7

Vascular Surgery

Lots of Choices for patients

  • Numerous options for VTOS treatment

– Conservative management – Surgery

  • Timing
  • Approach
  • Adjuncts
  • CARE SHOULD BE INDIVIDUALIZED

Vascular Surgery

Technical Aspects

  • Infraclavicular approach
  • Vein reconstruction
  • Timing of post-op venogram/venoplasty?

Vascular Surgery Vascular Surgery

slide-8
SLIDE 8

8

Vascular Surgery Vascular Surgery

Courtesy of J. Ernesto Molina

Vascular Surgery

Courtesy of J. Ernesto Molina

Vascular Surgery

Courtesy of J. Ernesto Molina

slide-9
SLIDE 9

9

Vascular Surgery

Courtesy of J. Ernesto Molina

Vascular Surgery

Courtesy of J. Ernesto Molina

The Hopkins Algorithm

  • Johns Hopkins protocol

– Thrombolysis (typically done prior to referral) – Systemic anticoagulation – First rib resection and scalenectomy

  • Restart Lovenox POD #3

– Two week follow-up venogram (+/- PTA)

  • Discontinue Lovenox if vein widely patent

– Four week clinic follow up with Duplex exam

  • Anticoagulation duration based on symptoms

and duplex findings

Vascular Surgery

Post op Orders

  • Resume lovenox POD#3-4
  • Schedule venogram POD 7-14

– No residual narrowing/no need for venoplasty

  • Finish 1 month total anticoagulation

– Need venoplasty

  • Complete one additional month anticoagulation
  • Resume full activity at 6 weeks
slide-10
SLIDE 10

10

Vascular Surgery

Some questions?

  • How about those with subacute or chronic

clot or delay in referral to surgery?

  • What happens to the athletes?

Vascular Surgery Vascular Surgery Vascular Surgery 27% 33%

slide-11
SLIDE 11

11

Vascular Surgery

Patient Demographics

All n=41 nTOS n=27 PSS n=14

Age (mean)

19.0 19.0 18.8

Female (%)

18 (44%) 17 (63%) 1 (7%)

Sport (%) Swimming

11 (27%) 11 (41%) 0 (0%)

Baseball

13 (33%) 4 (14%) 9 (65%)

Synchronized Swimming

2 (5%) 2 (7%) 0 (0%)

Volleyball

2 (5%) 1 (4%) 1 (7%)

Rowing

4 (10%) 3 (11%) 1 (7%)

Football

1 (2%) 0 (0%) 1 (7%)

Water Polo

5 (12%) 3 (11%) 2 (14%)

Weight Lifting

1 (2%) 1 (4%) 0 (0%)

Wrestling

1 (2%) 1 (4%) 0 (0%)

Diving

1 (2%) 1 (4%) 0 (0%)

Affected side Right (%)

26 (63%) 14 (52%) 12 (86%)

Affected Side Dominant (%)

28 (68%) 16 (59%) 12 (86%)

Bilateral (%)

1 (2%) 1 (4%) 0 (0%)

p=.0007

Vascular Surgery

Patient Demographics

All n=41 nTOS n=27 PSS n=14

Age (mean)

19.0 19.0 18.8

Female (%)

18 (44%) 17 (63%) 1 (7%)

Sport (%) Swimming

11 (27%) 11 (41%) 0 (0%)

Baseball

13 (33%) 4 (14%) 9 (65%)

Synchronized Swimming

2 (5%) 2 (7%) 0 (0%)

Volleyball

2 (5%) 1 (4%) 1 (7%)

Rowing

4 (10%) 3 (11%) 1 (7%)

Football

1 (2%) 0 (0%) 1 (7%)

Water Polo

5 (12%) 3 (11%) 2 (14%)

Weight Lifting

1 (2%) 1 (4%) 0 (0%)

Wrestling

1 (2%) 1 (4%) 0 (0%)

Diving

1 (2%) 1 (4%) 0 (0%)

Affected side Right (%)

26 (63%) 14 (52%) 12 (86%)

Affected Side Dominant (%)

28 (68%) 16 (59%) 12 (86%)

Bilateral (%)

1 (2%) 1 (4%) 0 (0%) p=.04 p=.18 p = 1

Vascular Surgery

Treatment Outcomes-PSS

All TOS (n=41) nTOS (n=27) PSS (n=14)

Operative

32 (78%) 18 (66.7%) 14 (100%)

Non-Operative

9 (22%) 9 (33.3%) 0 (0%)

Thrombolysis

13 (31.7%)

  • 13 (92.9%)

Mean timing of Thrombolysis (days prior to surgery, range)

84 (2-730)

  • 84 (2-730)

Length of Symptoms before Treatment (mean, months)

7.8 11 (SURG-15.1/ NONOP-3) 1.6

Return to Full Sport (%)

35 (85.4%) 22 (81.5%) 13 (92.9%)

Time to Pain Free (mean, months)

2.7 3.4 1.9

Time to Return Full Sport (mean, months)

4.6 4.4 4.7

Average Duration of Post-Op Anti-coagulation (months)

2.3

  • 2.3

Vascular Surgery

Treatment Outcomes-PSS

All TOS (n=41) nTOS (n=27) PSS (n=14)

Operative

32 (78%) 18 (66.7%) 14 (100%)

Non-Operative

9 (22%) 9 (33.3%) 0 (0%)

Thrombolysis

13 (31.7%)

  • 13 (92.9%)

Mean timing of Thrombolysis (days prior to surgery, range)

84 (2-730)

  • 84 (2-730)

Length of Symptoms before Treatment (mean, months)

7.8 11 (SURG-15.1/ NONOP-3) 1.6

Return to Full Sport (%)

35 (85.4%) 22 (81.5%) 13 (92.9%)

Time to Pain Free (mean, months)

2.7 3.4 1.9

Time to Return Full Sport (mean, months)

4.6 4.4 4.7

Average Duration of Post-Op Anti-coagulation (months)

2.3

  • 2.3
  • 64% with complete resolution
  • 36% with partial thrombus

burden

slide-12
SLIDE 12

12

Vascular Surgery

Treatment Outcomes-PSS

All TOS (n=41) nTOS (n=27) PSS (n=14)

Operative

32 (78%) 18 (66.7%) 14 (100%)

Non-Operative

9 (22%) 9 (33.3%) 0 (0%)

Thrombolysis

13 (31.7%)

  • 13 (92.9%)

Mean timing of Thrombolysis (days prior to surgery, range)

84 (2-730)

  • 84 (2-730)

Length of Symptoms before Treatment (mean, months)

7.8 11 (SURG-15.1/ NONOP-3) 1.6

Return to Full Sport (%)

35 (85.4%) 22 (81.5%) 13 (92.9%)

Time to Pain Free (mean, months)

2.7 3.4 1.9

Time to Return Full Sport (mean, months)

4.6 4.4 4.7

Average Duration of Post-Op Anti-coagulation (months)

2.3

  • 2.3

Vascular Surgery

Summary

  • High index of suspicion for TOS patients
  • Good prognosis for athletes

– 82% nTOS, 93% PSS – full return to sport

  • Keys to success:

– Multidisciplinary approach to TOS patients

  • Sports medicine, orthopedics, physical therapy,

team physicians, vascular surgeons, etc.

  • Reporting standards and registries

upcoming

Vascular Surgery

Thank You