warfarin and Thoracic-Outlet-Syndrome

Because of the small numbers of thoracic outlet syndrome (TOS) patients treated with bilateral first rib resection and scalenectomy (FRRS), this patient subset has not been well studied. We examined a large cohort of TOS patients who underwent bilateral FRRS to evaluate patient characteristics and outcomes.. Patients treated with bilateral FRRS at Johns Hopkins Medical Institutions from 2003 to 2012 were identified by review of a prospectively maintained database. Statistical analysis compared patients with unilateral and bilateral FRRS and bilateral patients with different TOS indications.. Fifty-three patients underwent bilateral FRRS with a mean follow-up of 11.4 months. Average time between operations was 17.0 months (range, 5.1-59.8 months). Compared with 408 unilateral FRRS patients, bilateral patients were younger (30 vs 35 years; P = .012), with no significant difference in gender. Among patients with dual-sided FRRS, 25 (47%) had bilateral neurogenic symptoms, 2 (4%) had bilateral arterial symptoms, and 26 (49%) had venous symptoms with the first side due to intermittent compression in 5 (second side: four, intermittent compression; one, neurogenic) and effort thrombosis in 21 (second side: 9, effort thrombosis; 8, intermittent compression; 4, neurogenic). Ten patients had prophylactic FRRS to prevent contralateral venous or arterial thrombosis, and eight had cervical ribs. Compared with neurogenic patients, venous patients were younger (25 vs 35 years; P < .001), with a trend toward more competitive athletes (seven venous vs two neurogenic). Symptomatic restenosis requiring dilation occurred after four FRRS for venous symptoms at a mean of 32.4 months, and rethrombosis occurred after four FRRS at a mean of 4 weeks (one treated with warfarin, three with tissue plasminogen activator), all on the primary side. Overall, 88% of FRRS for symptomatic TOS led to resolved symptoms at last follow-up.. Bilateral FRRS is an effective method for treatment of TOS. Venous bilateral patients more often are younger, are competitive athletes, and require close postoperative monitoring for recurrent stenosis and thrombosis.

Topics: Adolescent; Adult; Age Factors; Aged; Angioplasty, Balloon; Anticoagulants; Child; Constriction, Pathologic; Female; Fibrinolytic Agents; Humans; Male; Middle Aged; Neck Muscles; Recurrence; Retrospective Studies; Ribs; Subclavian Artery; Subclavian Vein; Thoracic Outlet Syndrome; Thrombosis; Tissue Plasminogen Activator; Treatment Outcome; Warfarin; Young Adult

Reported here is a 22-year-old professional wrestler who was diagnosed to have Paget-Schroetter syndrome after Greco-Roman wrestling. On substantial neuromuscular examination and laboratory testing, he was found to have also thoracic outlet syndrome and heterozygous mutations for factor V Leiden and methyltetrahydrofolate reductase genes. To the best knowledge of the authors, the concomitance of these pathologies is discussed for the first time in the literature.

Topics: Activated Protein C Resistance; Anticoagulants; Aspirin; Enoxaparin; Factor V; Heterozygote; Humans; Magnetic Resonance Angiography; Male; Methylenetetrahydrofolate Reductase (NADPH2); Occupational Diseases; Subclavian Vein; Thoracic Outlet Syndrome; Thrombophilia; Upper Extremity Deep Vein Thrombosis; Warfarin; Wrestling; Young Adult

Although venous thrombosis (thrombophlebitis) is well known, there are uncommon manifestations which are seen infrequently, discussed rarely, and documented poorly. Experiences with 38 patients in seven categories are discussed in terms of our results and the pertinent reports of others. Pulmonary necrosis after embolic pulmonary infarction (six patients) may require tube thoracotomy and/or lung resection and contraindicate further heparin therapy. Iliac and/or femoral vein thrombosis occasionally fails to recanalize. Long-standing occlusion (18 patients) may be benefited by a cross-over saphenous vein graft. Left iliac venous occlusion secondary to pressure from the crossing right iliac artery (four patients) may indicate repair or bypass. Budd-Chiari syndrome (thrombosis of the hepatic venous outflow) was, in a single patient, carried past a critical period by a long Dacron tube shunt graft from the umbilical vein to the azygos vein. Subclavian and axillary venous thrombosis due to thoracic outlet pressure syndrome (three patients) often responds to heparin but may require thrombectomy; later resection of the first rib is indicated. Phlegmasia cerulea dolens (blue phlebitis) with tissue gangrene (three patients) requires immediate venous thrombectomy and subsequent heparinization. The occluded inferior vena cava (three patients) remains a challenging unsolved problem.

Topics: Adult; Aged; Arteries; Blood Pressure; Blood Vessel Prosthesis; Budd-Chiari Syndrome; Child; Female; Femoral Vein; Gangrene; Heparin; Humans; Iliac Vein; Male; Middle Aged; Necrosis; Pulmonary Embolism; Subclavian Vein; Thoracic Outlet Syndrome; Thrombophlebitis; Transplantation, Autologous; Veins; Vena Cava, Inferior; Warfarin