SS20 - Surgical Outcomes for Occluded Venous Thoracic Outlet Syndrome following Transaxillary First Rib Resection

Objectives: Surgical decompression via transaxillary first rib resection (TFRR) is recommended following restoration of venous patency in patients presenting with venous thoracic outlet syndrome (VTOS) due to significant risk of re-occlusion. We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillo-subclavian veins in VTOS.

Methods: We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillo-subclavian vein between 2003 – 2023. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: < 4 weeks, 4-12 weeks and >12 weeks. We evaluated the association of TFRR timing with one-year outcomes including patency and symptomatic improvement. We used chi-square test to compare baseline characteristics and postoperative outcomes.

Results: Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillo-subclavian vein (median age 30.0 years, 42.7% female, 8.8% non-White), of which 28 patients had occlusion < 4 weeks, 36 patients had occlusion 4-12 weeks, and 39 patients had occlusion >12 weeks (Table I). Postoperative venogram performed 2-3 weeks after TFRR demonstrated that 78.6% in the < 4 weeks group, 72.2% in the 4-12 weeks group and 61.5% in the >12 weeks group had some degree of recanalization (P=0.76) (Table II). Postoperative venoplasties were successfully performed in 60 patients with stenosis of the axillo-subclavian vein at the time of postoperative venogram. After a median follow-up of 12 months, 79.2% in the < 4 weeks group, 73.3% in the 4-12 weeks group, and 73.3% in the >12 weeks group had patent axillo-subclavian veins based on duplex ultrasound (P=0.86). Among patients who underwent postoperative venoplasty, 80.0%, 85.0% and 100% in the < 4 weeks, 4-12 weeks and >12 weeks groups respectively demonstrated patency at 10-14 months (P=0.31) (Table III). Symptomatic improvement was reported in 95.7% in the < 4 weeks group, 96.7% in the 4-12 weeks group and 93.5% in the >12 weeks group (P=0.84).

Conclusions: TFRR offers excellent postoperative outcomes for VTOS patients, even in cases of completely occluded axillo-subclavian veins, regardless of the chronicity of the occlusion. Within 14 months, 93.5 - 96.7% of patients experienced symptomatic improvement, and more than 70% attained venous patency. Post-TFRR venoplasties further enhance results, achieving a remarkable patency rate of more than 80.0% by 14 months postoperatively.