Indian Journal of Vascular and Endovascular Surgery

LETTER TO EDITOR
Year
: 2018  |  Volume : 5  |  Issue : 4  |  Page : 302-

Optimal therapy for venous thoracic outlet syndrome


Yasser Ali Kamal 
 Department of Cardiothoracic Surgery, Minia University, El-Minya, Egypt

Correspondence Address:
Dr. Yasser Ali Kamal
Department of Cardiothoracic Surgery, Minia University, El-Minya
Egypt




How to cite this article:
Kamal YA. Optimal therapy for venous thoracic outlet syndrome.Indian J Vasc Endovasc Surg 2018;5:302-302


How to cite this URL:
Kamal YA. Optimal therapy for venous thoracic outlet syndrome. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2020 Aug 8 ];5:302-302
Available from: http://www.indjvascsurg.org/text.asp?2018/5/4/302/247270


Full Text



Sir,

We read with an interest the short review by Stephen et al. in issue 5, volume 3, of Indian Journal of Vascular and Endovascular Surgery.[1] This article is concise and valuable as it provides a guide to diagnose and treat venous thoracic outlet syndrome (VTOS) which constitutes one of the controversial clinical conditions of TOS. The authors clarified the important aspects of the management of VTOS, but we have some scientific notes which may support the educational aim of their review.

Regarding the epidemiology of VTOS, effort-induced thrombosis of the upper limb ranges from 1% to 4% of all venous thrombosis. Overall, VTOS accounts for about 5% of all TOS syndromes, and axillo-subclavian venous thrombosis is seen more often than nonthrombotic obstruction.[2],[3]

Considering treatment options, the authors highlighted the role of anticoagulation, catheter-directed thrombolysis/thrombolytic therapy, stenting after anticoagulation and catheter-directed thrombolysis, first-rib resection, and venous reconstruction. In addition, the authors answered some questions related to the challenging situations faced during the treatment of VTOS. We would like to highlight the emerging role of hybrid procedures for the treatment of VTOS where the endovascular techniques are combined to open surgery with long-term improvement of venous patency and avoidance of recurrence. Moreover, this combined treatment for VTOS results in the resolution of symptoms and improvement of the functional status, but more studies are recommended.[4]

The authors classified VTOS as described in literature into three types: intermittent venous obstruction, secondary venous thrombosis, and primary effort thrombosis. However, if we consider the patient presentations, VTOS may be further classified into three clinical types (acute, chronic, and intermittent), which may guide the treatment of VTOS.[5]

In acute cases (<6 weeks), the option of treatment is catheter-directed thrombolysis with early surgical decompression. In chronic cases (≥6 weeks), surgical decompression is beneficial when there is stenosis or occlusion of the subclavian vein, but total occlusion indicates thrombolysis before surgery. For cases with chronic intermittent venous obstruction without evidence of thrombosis or significant stenosis, only surgical decompression is required. Venoplasty of a residual subclavian vein stenosis may be considered to reduce the risk of re-thrombosis after decompression for acute and chronic cases, but thrombolysis, anticoagulation, or venoplasty are generally not required in cases with intermittent obstruction.[5]

In conclusion, a simple guide for the treatment of VTOS in accordance to the clinical presentation is important to provide an appropriate management relevant to its etiology and severity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Stephen E, Kota AA, Selvaraj D, Samuel V, Premkumar P, Agarwal S. Venous thoracic outlet syndrome: A short review. Indian J Vasc Endovasc Surg 2018;5:168-73.
2Brooke BS, Freischlag JA. Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol 2010;25:535-40.
3Tsekouras N, Comerota AJ. Current trends in the treatment of venous thoracic outlet syndrome: A comprehensive review. Interv Cardiol 2014;6:103-15.
4De Caridi G, Massara M, Greco M, Villari S, Squillaci D, Spinelli F. Hybrid management of Paget–Schroetter syndrome due to thoracic outlet syndrome. Gen Thorac Cardiovasc Surg 2016;64:109-12.
5Hussain MA, Aljabri B, Al-Omran M. Vascular thoracic outlet syndrome. Semin Thorac Cardiovasc Surg 2016;28:151-7.