EXERCISE INDUCED LEFT ARM 2% in the general population. SWELLING - - PowerPoint PPT Presentation

4/18/2015 1

EXERCISE INDUCED LEFT ARM SWELLING

Bala Ramanan, MBBS 1st year vascular surgery fellow

INTRODUCTION

• The incidence of thoracic outlet syndrome (TOS) is approximately 0.3-

2% in the general population.

• The most common age range is 25 to 40 years.
• Venous TOS accounts for 2-3% of cases.
• Controversies in the management involve what treatment should be

done immediately and which type of treatment should be implemented.

Case Presentation

• 37 year old male.
• Presented to ED with swelling , purplish discoloration and prominence of the veins

in his left upper extremity for 5 days after vigorous exercise.

• No previous symptoms , trauma or instrumentation.
• PMH: hashimoto’s thyroiditis, psoriasis.
• PSH: bilateral inguinal hernia repairs.
• Medications: synthroid.
• SH: no smoking, alcohol or drug use.

Physical Examination

• Left upper extremity- non tender, compartments soft, visible veins over the arm,

normal motor and sensory exam.

• Pulses: Bilateral radial pulses 2+

Imaging

4/18/2015 2 What are the initial management options?

• A. Discharge home from ED on

lovenox bridge to warfarin.

• B. Anticoagulation with heparin drip,

hypercoagulable workup and discharge home on warfarin for 3-6 months.

• C. Heparin drip, venogram and

catheter directed thrombolysis and mechanical thrombectomy.

• D. Open surgical thrombectomy.

D i s c h a r g e h

• m

e f r

• m

E D . . A n t i c

• a

g u l a t i

• n

w i t h h e . . . H e p a r i n d r i p , v e n

• g

r a m . . . O p e n s u r g i c a l t h r

• m

b e c . . .

3% 10% 87% 0%

Case Management

• Started on a heparin drip.
• Underwent catheter directed thrombolysis and mechanical

thrombectomy.

• Repeat Venogram on POD #1 showed patent subclavian vein with
• stenosis. He underwent venoplasty of the subclavian vein using 6

mm and 8 mm balloons with no significant change in the stenosis. PRETREATMENT VENOGRAM POST-THROMBOLYSIS VENOGRAM

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POST-VENOPLASTY VENOGRAM

How would you further manage this patient?

• A. Discharge home on low molecular

weight heparin bridge to warfarin for 3-6 months.

• B. Thoracic outlet decompression

surgery in the same hospital stay.

• C. Discharge home on anticoagulation

followed by thoracic outlet decompression surgery at a later time.

D i s c h a r g e h

• m

e

• n

l

• w

. . . T h

• r

a c i c

• u

t l e t d e c

• m

p r e . . . D i s c h a r g e h

• m

e

• n

a n t i c . . .

4% 39% 57%

What intervention would you perform to restore vein patency?

• A. Intraoperative balloon venoplasty.
• B. Delayed balloon venoplasty +/-

stent.

• C. Intraoperative venolysis/ vein

patch.

I n t r a

• p

e r a t i v e b a l l

• n

v . . . D e l a y e d b a l l

• n

v e n

• p

l a s t . I n t r a

• p

e r a t i v e v e n

• l

y s i s / . . .

17% 70% 13%

Case Management

• 1. Ultrasound-guided retrograde left basilic vein access.
• 2. Left subclavian nonselective venogram.
• 3. Left 1st rib resection.
• 4. Subclavian venolysis.
• 5. Percutaneous balloon angioplasty of subclavian vein to 12 mm.

Postoperative course

Discharged home on warfarin on POD 5 for 3 months then switched to aspirin.

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POST BALLOON VENOPLASTY IN OR STEP 1: IMMEDIATE THROMBOLYSIS

• Immediate thrombolysis of venous TOS is favored as the syndrome

can evolve very rapidly into a chronic stage with irreversible fibrotic changes of the vein.

• This can lead to total obliteration with chronic edema and disability.

STEP 2: PREVENTION OF RECURRENCE

Role of venous stents alone without TOS decompressive surgery

• Urschel et al.*studied 22 patients who had venous stents inserted without TOS

decompressive surgery. All 22 stents occluded within 6 weeks after insertion. The authors concluded that venous stents alone are contraindicated in venous TOS.

• Meier and colleagues# studied outcome of venous stents after initial thrombolysis

for venous TOS. They observed stent fractures in patients who had venous stents alone.

*Urschel HC, Patel AN. Ann Thorac Surg 2003;75:1693-6. 13. #Meier GH, et al.J Vasc Surg 1996;24:974-83.

Timing of TOS decompressive surgery

• Kunkel and Machleder* in 1989 described and algorithm of initial thrombolysis

therapy followed by 3 months of anticoagulation to allow the inflammation to subside and then delayed transaxillary first rib resection and scalenectomy in 17 patients.

• Angie and colleagues# reviewed 18 consecutive patients and for the first time

compared outcomes of 9 patients undergoing immediate surgery and 9 patients undergoing staged therapy with excellent results in the early surgery group.

• Early decompressive surgery has now been widely adapted for treatment of venous

TOS.

• In patients unable to receive early decompression- anticoagulation is followed by

decompression at a convenient time.

*J.M. Kunkel, H.I. Machleder. Arch Surg, 124 (1989), pp. 1153–1158 #Angie et al. Ann Vasc Surg, 15 (2001), pp. 37–42.

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Direct interventions on the vein to re-establish normal caliber

• Schneider et al. *described balloon angioplasty alone during the

surgery for TOS decompression in 25 patients.

• Balloon angioplasty with stent implant as a delayed second

intervention has been reported by Hall et al.# and Kreienberg et al.!

• Direct surgical intervention- simple venotomy or patch enlargement
• f the vein during surgery for TOS decompression has been described

by Molina and colleagues$ with 100% success rate in a cohort of 97 patients.

*Schneider DB, et al. J Vasc Surg 2004;40:599-603. #Hall LD,et al. J Vasc Interven Radiol 1995;6:565-70. 16. !Kreienberg PB, et al. J Vasc Surg 2001;33:S100-5. $ Molina et al. J Vasc Surg 2007; 45(2):328-34.

Conclusions

• Venous TOS occurs in young patients after vigorous

exercise.

• Immediate thrombolysis is the first line of therapy.
• Venous stents alone are contraindicated.
• Timing of TOS decompression surgery is

controversial.

• Vein stenosis can be treated with percutaneous

angioplasty, venolysis or patch venoplasty.