Subclavian vein stenosis and axillary vein 'effort thrombosis'. Age and the first rib bypass collateral, thrombolytic therapy and first rib resection.

Three patients presented with axillary vein 'effort thrombosis'. Intravenous streptokinase for 3 days followed by heparin for 10 days restored patency and relieved symptoms. Pretreatment diagnosis and the effect of streptokinase were confirmed venographically and an abnormality in the subclavian vein just medial to the first rib was demonstrated. This stenosis was most severe and had a prominent bypass collateral in the oldest patient. It is proposed that, in the absence of superimposed thrombosis, the damage to the vein in predisposed patients is progressive with age, with establishment of permanent collaterals. Transaxillary first rib resection is advised to prevent compression of the veins in the thoracic outlet.