Venous Thoracic Outlet Syndrome (vTOS): May Surgery be a Solution in Chronic Form?

Abstract

Background: Chronic venous thoracic outlet syndrome (vTOS) is characterized by persistent compression of the subclavian vein (SCV) for >3 months after the initial primary upper extremity deep vein thrombosis (DVT) event often resulting in significant morbidity and post-thrombotic syndrome (PTS). While treatment algorithms for acute vTOS are well-defined, management of chronic vTOS remains nonstandardized and underexplored. This study aims to assess outcome of thoracic outlet decompression in patients with chronic vTOS, providing insights into optimal management.

Methods: We conducted a retrospective review of patients with chronic vTOS who underwent surgical decompression at Humanitas Gavazzeni Hospital between January 2013 and April 2024. Diagnosis was based on clinical presentation and imaging studies. Preoperatively, patients were stratified into 3 groups according to the extent of venous recanalization: group I (complete recanalization), group II (partial recanalization and/or collateral circulation), and group III (persistent occlusion with collateral compression). All patients underwent first-rib resection through a transaxillary approach. Postoperative outcome, including symptoms relief and imaging findings, were assessed through follow-up visits.

Results: A total of 83 patients were included, with an 8% postoperative complication rate. Group I showed the most favorable outcome, with 89% achieving full symptoms resolution, while group II patients benefited from adjunctive balloon angioplasty, improving venous function in 61% of cases. In group III, decompression improved collateral circulation despite persistent SCV occlusion, resulting in significant symptomatic relief. Across groups, 83% of patients reported substantial improvement in symptoms, facilitating a return to daily activities and cessation of anticoagulation. All patients in groups I and III were able to definitively discontinue anticoagulant therapy.

Conclusion: Decompressive surgery through transaxillary first-rib resection significantly relieves symptoms in chronic vTOS, and the decision should be guided by preoperative imaging characteristics and objective clinical analyses. Stratification by recanalization and compression severity can help predict surgical success and guide postoperative management, including the use of adjunctive endovascular interventions.