MedifocusHealth

Treatment for vascular TOS must address three issues:

• The presence of a blood clot
• Extrinsic (external) compression of the blood vessel
• Intrinsic (internal) damage to the blood vessel

Treatment of Arterial TOS

Treatment for arterial TOS includes:

• Initiation of anticoagulant therapy (e.g. heparin, warfarin)

• Surgical decompression of the blood vessel by resection of either/or:

  • cervical rib
  • bony abnormalities
  • fibrous bands

• Arterial reconstruction

Additional surgical procedures depend on the clinical picture following surgical decompression, such as the presence and extent of stenosis (narrowing of the blood vessel by the clot). If distal embolism (clot traveling through the bloodstream) or other complications are present, they require close observation and may result in further surgical procedures, (e.g., arterial bypass). Generally, the more distant the occlusion from the embolism, the more difficult it is to reestablish proper blood flow (perfusion). This increases the likelihood of amputation, although this is very rarely necessary.

Treatment of Venous TOS

Treatment for venous TOS includes:

• Anticoagulant medications
• Thrombolysis - also called venolysis
• Surgical resection of the first rib

Anticoagulant medications (e.g., heparin, warfarin)

Anticoagulants are the cornerstone of therapy for venous thrombosis. They help to maintain patency (open flow) of the collateral vessels which may form around the site of the occlusion and may also reduce the growth of the thrombus if it does not completely resolve with treatment.

Thrombolysis

Thrombolysis involves breaking up of the blood clot by embedding a catheter tip in the thrombus and delivering a thrombolytic agent (e.g. streptokinase). New suction devises enable safer mechanical removal of the bits and pieces of clot. This procedure is usually done while the patient is treated with anticoagulants and achieves a higher rate of clot resolution than with the use of anticoagulation medication alone.

The advantages of thrombolysis include:

• Early restoration of venous patency (open flow) which minimizes damage to the vessel walls
• Reduces risk of long term complications

The success of thrombolysis typically depends on the age of the thrombus. Thrombolysis of a thrombus a few days old usually results in a 80-100% success rate. In addition, young and otherwise healthy patients are the most promising candidates for the success of this procedure. Following thrombolysis, patients usually undergo elective first rib resection. Failure to perform surgical resection of the first rib following thrombylyis increases the risk of recurrence of the thrombus.

Adverse effects of thrombolysis include:

• Minor bleeding complications, (e.g., at the venous puncture site).
• Post-thrombotic syndrome (chronic aching and/or swelling of the affected arm and hand)

Thrombolysis is contraindicated in patients with various comorbid conditions, including:

• History of hemorrhagic stroke
• Active bleeding
• Neurosurgical procedures within the past 2 months
• Sensitivity or allergy to thrombolytic agents
• Any surgery within the past 10 days

Surgical Resection of the First Rib

Surgery typically involves resection of part of the first rib or any other abnormalities that are causing compression on the subclavian vein. There is presently no consensus regarding how soon surgery should be performed following thrombolysis. Some physicians prefer initiating conservative therapy which may include: