Case study: Recurrent deep vein thrombosis in thoracic outlet syndrome

LAS VEGAS — Researchers from Johns Hopkins Hospital reported a case study of a 53-year-old woman who presented to the emergency room for right upper extremity deep vein thrombosis after rib resection and subclavian vein stent placement 15 years ago.

Holly Grunebach, PA-C, and Ying Wei Lum, MD, from the Department of Vascular Surgery and Endovascular Therapy at Johns Hopkins Hospital in Baltimore reported the case at the American Academy of Physician Assistants (AAPA) 2017 conference.

An ultrasound showed narrowing within the right subclavian vein stent with partially occlusive thrombus along with occlusive thrombus in the cephalic and paired brachial veins. A computed tomography angiography of the chest confirmed the ultrasound findings and remnant right first rib.

The patient was discharged on therapeutic lovenox, and she returned 2 weeks later for right infraclavicular first rib resection with right subclavian stent venoplasty.

The researchers note that 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.

The investigators concluded that recurrent venous thoracic outlet syndrome is uncommon, but it requires a multifactorial approach in management targeted to treat the etiology. For this patient, they said surgical treatment including resection of the remnant first rib and venoplasty to open the subclavian stent would provide better long-term relief; continued anticoagulation therapy would improve the long-term patency of the subclavian vein, further reducing the risk of recurrence.

Definitive treatment for thoracic outlet syndrome, the investigators indicated, is surgical decompression with first rib resection, anterior scalenectomy, and venolysis followed by anticoagulation and physical therapy. “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,” they wrote. “This data was not known when the patient first underwent treatment for venous thoracic outlet syndrome. This, combined with the residual first rib, which may have damaged the stent secondary to compression, might have caused re-occlusion in this patient.”

AAPA 2017 continues through Friday, May 19th. Visit http://www.aapaconference.org for more information.

Reference

1. Grunebach H, Lum YW. Not again! Management of recurrent deep vein thrombosis in thoracic outlet syndrome. Presented at the American Academy of Physician Assistants 2017 conference; May 15-19, 2017; Las Vegas.