Disclosures How my current algorithm for venous Nothing to - PowerPoint PPT Presentation

Disclosures How my current algorithm for venous • Nothing to Disclose Thoracic Outlet Syndrome has evolved Jason T. Lee UCSF Vascular Symposium 2015 Stanford Vascular & Endovascular Surgery Vascular Surgery Basic Facts • 3-80/1000 population in US • Patient visits – Will see 4.7 physicians prior to diagnosis – Will see 6.7 physicians prior to surgery • Lack of standardized diagnostic or treatment criteria Huang et al 2004 Landry et al 2001 Vascular Surgery Vascular Surgery 1

RESULTS Epidemiology INCIDENCE • Analysis of large administrative database to determine national trends of surgical intervention for Thoracic Outlet Syndrome – Incidence of operation – Type of TOS – Type of Surgeon – Mortality – Inpatient complications Range 1568-3740 cases/year, median 2524 96% neurogenic – Volume effect 3% venous 1% arterial Vascular Surgery Vascular Surgery RESULTS RESULTS TYPE OF SURGEON Neurogenic vs. Venous Neurogenic Venous P-value 7% 6% Median age decile 30-39 20-29 <0.0001 VASCULAR THORACIC NEUROSURGEON % female 68.6% 38.4% <0.0001 20% 67% ORTHOPEDIC Hospital stay (days) 2.7 6.7 <0.0001 Mortality 0.04% 1.4% <0.001 Vascular Surgery Vascular Surgery 2

RESULTS Anatomy Complications • High Volume Hospital – counted the number of procedures performed by each hospital each year and assigned the top tercile as high volume – >15 cases per year associated with lower complication rate • Odds Ratio 0.43 (p=0.007) • Teaching status – Equal between teaching and non-teaching hospitals Vascular Surgery Vascular Surgery Venous TOS Historical Perspective • 1875 - Paget describes “gouty phlebitis” of UE, • Subclavian vein thrombosis which he attributes to vasospasm – Overuse injury • 1884 - Schroetter postulates subclavian/axillary vein thrombosis as cause – Hypertrophied scalene • 1949 - Hughes reviews 320 published cases, coins – Costoclavicular ligament “Paget-Schroetter syndrome” – Hypercoagulable state • 1950s - subclavian vein catheters come into use • Presentation • 1960s - association of primary SV/AV thrombosis with exertion recognized, leading to coining of “effort – swelling thrombosis” – DVT • 1970s - subclavian vein catheterizations recognized – Muscle ache/fatigue as secondary cause of SV/AV thrombosis Vascular Surgery Vascular Surgery 3

Development of a treatment 18 yo baseball catcher paradigm for vTOS Working out on weekend Swollen R arm • Simple observation and anticoagulation yields Duplex showed axillo- poor results subclavian occlusion • Open surgical thrombectomy leads to high incidence of early rethrombosis • Early thrombolysis is effective as initial strategy – Rapidly restores patency – Confirms anatomy – safe Donayre et al, Am J Surg 1996 Machleder, Sem Vasc Surg 1992 Deweese et al, Circulation 1970 Vascular Surgery Vascular Surgery Audience participation 18 yo baseball catcher Working out on weekend Swollen R arm A. anticoagulation only Duplex showed axillo- B. thrombolysis then anticoagulation subclavian occlusion Venography C. thrombolysis with immediate rib 64% Thrombolysis resection D. thrombolysis, anticoagulation, 27% delayed rib resection 6% 3% Vascular Surgery Vascular Surgery 4

18 yo baseball catcher 18 yo baseball catcher Working out on weekend Working out on weekend Swollen R arm Swollen R arm Duplex showed axillo- Duplex showed axillo- subclavian occlusion subclavian occlusion Venography Venography Thrombolysis Thrombolysis Mechanical Mechanical Chemical Chemical Balloon venoplasty Vascular Surgery Vascular Surgery Treatment options Immediate Surgery vs. Conservative Approach • Immediate surgery • Trial of • Immediate surgery • Conservative anticoagulation – Avoid longer regimen of – Less inflammation around anticoagulation vein leading to safer – Surgery if symptoms operation • If surgery, what are – Return to baseline activity persist sooner – Allows for possibility of the issues? non-operative management – Approach – Venoplasty/stent – Venolysis/venous replacement Machleder, J Vasc Surg 1993 Angle et al, Ann Vasc Surg 2001 Lee et al, J Vasc Surg 2000 Vascular Surgery Vascular Surgery 5

Vascular Surgery Vascular Surgery Stanford Algorithm-CURRENT - Duplex Repeat & Suspected Ultrasound Observe PSS + First Rib Yes Resection Venogram & Thrombolysis Sxs at 3 Months? Heparin to Discontinue Warfarin No Athlete warfarin Young (<28) Yes No First Rib Sxs at One Continue Month? Resection warfarin Vascular Surgery Vascular Surgery 6

Lots of Choices for patients Technical Aspects • Numerous options for VTOS treatment • Infraclavicular approach – Conservative management • Vein reconstruction – Surgery • Timing of post-op venogram/venoplasty? • Timing • Approach • Adjuncts • CARE SHOULD BE INDIVIDUALIZED Vascular Surgery Vascular Surgery Vascular Surgery Vascular Surgery 7

Courtesy of J. Ernesto Molina Vascular Surgery Vascular Surgery Courtesy of J. Ernesto Molina Courtesy of J. Ernesto Molina Vascular Surgery Vascular Surgery 8

Courtesy of J. Ernesto Molina Courtesy of J. Ernesto Molina Vascular Surgery Vascular Surgery The Hopkins Algorithm Post op Orders • Resume lovenox POD#3-4 • Johns Hopkins protocol • Schedule venogram POD 7-14 – Thrombolysis (typically done prior to referral) – Systemic anticoagulation – No residual narrowing/no need for venoplasty – First rib resection and scalenectomy • Finish 1 month total anticoagulation • Restart Lovenox POD #3 – Need venoplasty – Two week follow-up venogram (+/- PTA) • Complete one additional month anticoagulation • Discontinue Lovenox if vein widely patent • Resume full activity at 6 weeks – Four week clinic follow up with Duplex exam • Anticoagulation duration based on symptoms and duplex findings Vascular Surgery 9

Some questions? • How about those with subacute or chronic clot or delay in referral to surgery? • What happens to the athletes? Vascular Surgery Vascular Surgery 33% 27% Vascular Surgery Vascular Surgery 10

Patient Demographics Patient Demographics All nTOS PSS All nTOS PSS n=41 n=27 n=14 n=41 n=27 n=14 Age (mean) Age (mean) 19.0 19.0 18.8 19.0 19.0 18.8 p=.0007 Female (%) Female (%) 18 (44%) 17 (63%) 1 (7%) 18 (44%) 17 (63%) 1 (7%) Sport (%) Sport (%) Swimming Swimming 11 (27%) 11 (41%) 0 (0%) 11 (27%) 11 (41%) 0 (0%) Baseball 13 (33%) 4 (14%) Baseball 13 (33%) 4 (14%) 9 (65%) 9 (65%) Synchronized Swimming 2 (5%) 2 (7%) 0 (0%) Synchronized Swimming 2 (5%) 2 (7%) 0 (0%) Volleyball Volleyball 2 (5%) 1 (4%) 1 (7%) 2 (5%) 1 (4%) 1 (7%) Rowing 4 (10%) 3 (11%) 1 (7%) Rowing 4 (10%) 3 (11%) 1 (7%) Football 1 (2%) 0 (0%) 1 (7%) Football 1 (2%) 0 (0%) 1 (7%) Water Polo Water Polo 5 (12%) 3 (11%) 2 (14%) 5 (12%) 3 (11%) 2 (14%) Weight Lifting 1 (2%) 1 (4%) 0 (0%) Weight Lifting 1 (2%) 1 (4%) 0 (0%) Wrestling 1 (2%) 1 (4%) 0 (0%) Wrestling 1 (2%) 1 (4%) 0 (0%) Diving Diving 1 (2%) 1 (4%) 0 (0%) 1 (2%) 1 (4%) 0 (0%) p=.04 Affected side Right (%) Affected side Right (%) 26 (63%) 14 (52%) 12 (86%) 26 (63%) 14 (52%) 12 (86%) Affected Side Dominant (%) Affected Side Dominant (%) p=.18 28 (68%) 16 (59%) 12 (86%) 28 (68%) 16 (59%) 12 (86%) Bilateral (%) Bilateral (%) p = 1 1 (2%) 1 (4%) 0 (0%) 1 (2%) 1 (4%) 0 (0%) Vascular Surgery Vascular Surgery Treatment Outcomes-PSS Treatment Outcomes-PSS All TOS nTOS PSS All TOS nTOS PSS (n=41) (n=27) (n=14) (n=41) (n=27) (n=14) Operative Operative 32 (78%) 18 (66.7%) 14 (100%) 32 (78%) 18 (66.7%) 14 (100%) Non-Operative Non-Operative 9 (22%) 9 (33.3%) 0 (0%) 9 (22%) 9 (33.3%) 0 (0%) Thrombolysis Thrombolysis 13 (31.7%) - 13 (92.9%) 13 (31.7%) - 13 (92.9%) Mean timing of Thrombolysis Mean timing of Thrombolysis 84 (2-730) - 84 (2-730) 84 (2-730) - 84 (2-730) (days prior to surgery, range) (days prior to surgery, range) • 64% with complete resolution Length of Symptoms before Length of Symptoms before 11 11 7.8 1.6 7.8 1.6 • 36% with partial thrombus Treatment (mean, months) Treatment (mean, months) (SURG-15.1/ NONOP-3) (SURG-15.1/ NONOP-3) Return to Full Sport (%) Return to Full Sport (%) burden 35 (85.4%) 22 (81.5%) 13 (92.9%) 35 (85.4%) 22 (81.5%) 13 (92.9%) Time to Pain Free (mean, Time to Pain Free (mean, 2.7 3.4 1.9 2.7 3.4 1.9 months) months) Time to Return Full Sport Time to Return Full Sport 4.6 4.4 4.7 4.6 4.4 4.7 (mean, months) (mean, months) Average Duration of Post-Op Average Duration of Post-Op 2.3 - 2.3 2.3 - 2.3 Anti-coagulation (months) Anti-coagulation (months) Vascular Surgery Vascular Surgery 11