The place of first rib resection in the management of axillary-subclavian vein thrombosis.

Eight patients with axillary-subclavian vein thrombosis were studied. Three presented acutely and five with chronic symptoms of pain and swelling exacerbated by and limiting normal use. Initial venography showed complete occlusion of the axillary vein in 7 cases and marked narrowing in the remaining patient. Venographic evidence of narrowing or occlusion was also seen in 6/8 clinically normal contralateral arms. One of these arms became symptomatic 2 years later, and required surgery. The patients presenting acutely were anticoagulated. Symptoms resolved slowly in 2 cases, but persisted in one. This patient and the five presenting chronic symptoms underwent decompression of the thoracic outlet by transaxillary resection of the first rib. Satisfactory decompression was confirmed at operation by eliciting and then abolishing "nipping" of the surgeon's finger between the first rib and the clavicle on abducting and then relaxing the arm. Symptomatic relief was achieved in 5/7 limbs thus treated (one patient had bilateral first rib resection). Although postoperative venographic improvement was seen in some cases, clinical success did not depend on recanalisation of the main axillary-subclavian vein. The two patients with persistent symptoms after first rib resection subsequently had venous bypass procedures. Despite initial patency, both had occluded with return of symptoms within 4 months.