Methods
Two vascular surgeons (IW/RJW) who routinely perform thoracic outlet surgery at University Hospital of Wales were included in the series. All patients presenting with a suspected diagnosis of PSS underwent complete history and examination followed by X-Ray of the thoracic inlet and duplex ultrasonography to confirm the diagnosis. If a thrombus was detected in the SV and there were no contraindications, a full discussion was held with the patient regarding venography and possible thrombolysis. The risks of thrombolysis were explained as were the potential benefits and if consenting underwent open surgical decompression following lysis. The selection of patients to undergo surgical decompression takes into account several factors. These include the age, whether it is the dominant arm affected, the duration of the thrombus within the vein, acceptance of risks of lysis and open surgery. Furthermore, if treated medically there is a risk of developing post phlebitic limb and associated morbidity in up to 46% of cases.13 Patients were initially treated with CDTL using tPA via the ipsilateral cephalic vein, at 1 mL/hr after a 10 mg bolus dose. This was repeated after 6 hours with a further venogram performed within 24 hours. tPA was either continued (for 6 further hours) or discontinued, depending on the residual thrombus load within the SV. Surgical decompression was then carried out in accordance with the IC, TA, and SC routes outlined previously, and all patients underwent first rib resection (FRR) under general anaesthetic. Patients were then commenced on antiplatelet therapy (aspirin) combined with 3-6 months of anticoagulation and latterly rivaroxaban. This was then stopped and antiplatelets were continued long-term. Venography was performed at six weeks post-surgery to assess patency and to treat residual stenosis if present.