Not Again! Management of Recurrent Deep Vein Thrombosis in Thoracic Outlet Syndrome
AAPA ePoster library. Grunebach H. 05/17/17; 180544; 215
Holly Grunebach
Holly Grunebach
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Abstract
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Purpose: Upper extremity deep vein thrombosis (DVT) can be the result of multiple etiologies, including thoracic outlet syndrome (TOS)1. The recommend treatment for this case is anticoagulation, surgical decompression with a post-operative venogram, and physical therapy2. With this treatment, the risk of re-current DVT is minimal3. However, if a patient does develop a recurrent upper extremity DVT, what is the course of management? This case presentation reviews patient management with emphasis on adequate 1st rib resection to reduce risk recurrent DVT, especially in patients with prior venous stenting. Case report: Patient is a 53 year old female who presented to the emergency room for right upper extremity DVT after rib resection and subclavian vein stent placement 15 years ago at another facility. This was confirmed by ultrasound which showed narrowing within the right subclavian vein stent with partially occlusive thrombus with occlusive thrombus in the cephalic and paired brachial veins. A CTA of the chest was done to further confirm the ultrasound findings and remnant right first rib. She was discharged on therapeutic lovenox. She returned two weeks later for right infraclavicular 1st rib resection with right subclavian stent venoplasty. This was complicated by a right hemothorax managed as part of her hospital course. Anticoagulation was restarted and she was discharged on Coumadin for a minimum of 3 months and physical therapy. Discussion: TOS is an uncommon condition that occurs when the subclavian artery, vein and/or the brachial plexus, is compressed by the anterior scalene muscle and first rib2. Venous TOS occurs as a result of a DVT in the subclavian vein after repeated compression when a web-like matrix forms within the vessel structure2. Definite treatment is surgical decompression with 1st rib resection, anterior scalenectomy and venolysis followed by anticoagulation and physical therapy2. Venous stenting has fallen out of favor as long term patency rates are poor, often felt to be secondary to low flow rates in the vein.3 This data was not known when the patient first underwent treatment for venous TOS. This combined with the residual first rib, which may have damaged the stent secondary to compression, might have caused re-occlusion in this patient. First rib resection can be done via a supraclavicular, infraclavicular or transaxillary incision3. Infraclavicular was selected for this patient to allow for be...
Purpose: Upper extremity deep vein thrombosis (DVT) can be the result of multiple etiologies, including thoracic outlet syndrome (TOS)1. The recommend treatment for this case is anticoagulation, surgical decompression with a post-operative venogram, and physical therapy2. With this treatment, the risk of re-current DVT is minimal3. However, if a patient does develop a recurrent upper extremity DVT, what is the course of management? This case presentation reviews patient management with emphasis on adequate 1st rib resection to reduce risk recurrent DVT, especially in patients with prior venous stenting. Case report: Patient is a 53 year old female who presented to the emergency room for right upper extremity DVT after rib resection and subclavian vein stent placement 15 years ago at another facility. This was confirmed by ultrasound which showed narrowing within the right subclavian vein stent with partially occlusive thrombus with occlusive thrombus in the cephalic and paired brachial veins. A CTA of the chest was done to further confirm the ultrasound findings and remnant right first rib. She was discharged on therapeutic lovenox. She returned two weeks later for right infraclavicular 1st rib resection with right subclavian stent venoplasty. This was complicated by a right hemothorax managed as part of her hospital course. Anticoagulation was restarted and she was discharged on Coumadin for a minimum of 3 months and physical therapy. Discussion: TOS is an uncommon condition that occurs when the subclavian artery, vein and/or the brachial plexus, is compressed by the anterior scalene muscle and first rib2. Venous TOS occurs as a result of a DVT in the subclavian vein after repeated compression when a web-like matrix forms within the vessel structure2. Definite treatment is surgical decompression with 1st rib resection, anterior scalenectomy and venolysis followed by anticoagulation and physical therapy2. Venous stenting has fallen out of favor as long term patency rates are poor, often felt to be secondary to low flow rates in the vein.3 This data was not known when the patient first underwent treatment for venous TOS. This combined with the residual first rib, which may have damaged the stent secondary to compression, might have caused re-occlusion in this patient. First rib resection can be done via a supraclavicular, infraclavicular or transaxillary incision3. Infraclavicular was selected for this patient to allow for be...
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