disclosures - ucsf cme pdfs... · – first rib resection and scalenectomy • restart lovenox pod...
TRANSCRIPT
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Stanford Vascular & Endovascular Surgery
Jason T. LeeUCSF Vascular Symposium 2015
How my current algorithm for venous Thoracic Outlet Syndrome
has evolved
Vascular Surgery
Disclosures
• Nothing to Disclose
Vascular 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
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Vascular Surgery
Epidemiology• 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
– Volume effect
Vascular Surgery
RESULTSINCIDENCE
Range 1568-3740 cases/year, median 252496% neurogenic3% venous1% arterial
Vascular Surgery
RESULTSTYPE OF SURGEON
VASCULARTHORACICNEUROSURGEONORTHOPEDIC67%20%
7% 6%
Vascular Surgery
RESULTSNeurogenic vs. Venous
Neurogenic Venous P-value
Median age decile 30-39 20-29 <0.0001
% female 68.6% 38.4% <0.0001
Hospital stay (days) 2.7 6.7 <0.0001
Mortality 0.04% 1.4% <0.001
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Vascular Surgery
RESULTSComplications
• 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
Anatomy
Vascular Surgery
Venous TOS
• Subclavian vein thrombosis– Overuse injury– Hypertrophied scalene– Costoclavicular ligament– Hypercoagulable state
• Presentation– swelling– DVT– Muscle ache/fatigue
Vascular Surgery
Historical Perspective• 1875 - Paget describes “gouty phlebitis” of UE,
which he attributes to vasospasm• 1884 - Schroetter postulates subclavian/axillary vein
thrombosis as cause• 1949 - Hughes reviews 320 published cases, coins
“Paget-Schroetter syndrome”• 1950s - subclavian vein catheters come into use• 1960s - association of primary SV/AV thrombosis
with exertion recognized, leading to coining of “effort thrombosis”
• 1970s - subclavian vein catheterizations recognized as secondary cause of SV/AV thrombosis
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Vascular Surgery
Development of a treatment paradigm for vTOS
• Simple observation and anticoagulation yields poor results
• 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 1996Machleder, Sem Vasc Surg 1992Deweese et al, Circulation 1970
Vascular Surgery
18 yo baseball catcher
Working out on weekend
Swollen R arm
Duplex showed axillo-subclavian occlusion
Vascular Surgery
Audience participation
A. anticoagulation only
B. thrombolysis then anticoagulation
C. thrombolysis with immediate rib resection
D. thrombolysis, anticoagulation, delayed rib resection 3%
64%
27%
6%
Vascular Surgery
18 yo baseball catcher
Working out on weekend
Swollen R arm
Duplex showed axillo-subclavian occlusion
Venography
Thrombolysis
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Vascular Surgery
18 yo baseball catcher
Working out on weekend
Swollen R arm
Duplex showed axillo-subclavian occlusion
Venography
Thrombolysis
Mechanical
Chemical
Vascular Surgery
18 yo baseball catcher
Working out on weekend
Swollen R arm
Duplex showed axillo-subclavian occlusion
Venography
Thrombolysis
Mechanical
Chemical
Balloon venoplasty
Vascular Surgery
Treatment options
• Immediate surgery
• If surgery, what are the issues?– Approach
– Venoplasty/stent– Venolysis/venous
replacement
• Trial of anticoagulation– Surgery if symptoms
persist
Vascular Surgery
Immediate Surgery vs. Conservative Approach
• Immediate surgery– Avoid longer regimen of
anticoagulation– Return to baseline activity
sooner
• Conservative– Less inflammation around
vein leading to safer operation
– Allows for possibility of non-operative management
Machleder, J Vasc Surg 1993Angle et al, Ann Vasc Surg 2001Lee et al, J Vasc Surg 2000
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Vascular Surgery Vascular Surgery
Vascular Surgery Vascular Surgery
SuspectedPSS
DuplexUltrasound
Venogram &Thrombolysis
Repeat &Observe
-
+
Heparin toWarfarin
Sxs at OneMonth?
First Rib Resection
YesContinue warfarin
No
Sxs at 3Months?
First Rib Resection
Discontinuewarfarin
Yes
No
Stanford Algorithm-CURRENT
Athlete
Young (<28)
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Vascular Surgery
Lots of Choices for patients
• Numerous options for VTOS treatment– Conservative management– Surgery
• Timing• Approach• Adjuncts
• CARE SHOULD BE INDIVIDUALIZED
Vascular Surgery
Technical Aspects
• Infraclavicular approach
• Vein reconstruction
• Timing of post-op venogram/venoplasty?
Vascular Surgery Vascular Surgery
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Vascular Surgery Vascular SurgeryCourtesy of J. Ernesto Molina
Vascular SurgeryCourtesy of J. Ernesto Molina
Vascular SurgeryCourtesy of J. Ernesto Molina
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Vascular SurgeryCourtesy of J. Ernesto Molina
Vascular SurgeryCourtesy of J. Ernesto Molina
The Hopkins Algorithm
• Johns Hopkins protocol– Thrombolysis (typically done prior to referral)– Systemic anticoagulation– First rib resection and scalenectomy
• Restart Lovenox POD #3– Two week follow-up venogram (+/- PTA)
• Discontinue Lovenox if vein widely patent– Four week clinic follow up with Duplex exam
• Anticoagulation duration based on symptoms and duplex findings
Vascular Surgery
Post op Orders
• Resume lovenox POD#3-4
• Schedule venogram POD 7-14– No residual narrowing/no need for venoplasty
• Finish 1 month total anticoagulation
– Need venoplasty• Complete one additional month anticoagulation
• Resume full activity at 6 weeks
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Vascular Surgery
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 Vascular Surgery
27%
33%
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Vascular Surgery
Patient DemographicsAll
n=41nTOSn=27
PSSn=14
Age (mean) 19.0 19.0 18.8
Female (%) 18 (44%) 17 (63%) 1 (7%)
Sport (%)
Swimming 11 (27%) 11 (41%) 0 (0%)
Baseball 13 (33%) 4 (14%) 9 (65%)
Synchronized Swimming 2 (5%) 2 (7%) 0 (0%)
Volleyball 2 (5%) 1 (4%) 1 (7%)
Rowing 4 (10%) 3 (11%) 1 (7%)
Football 1 (2%) 0 (0%) 1 (7%)
Water Polo 5 (12%) 3 (11%) 2 (14%)
Weight Lifting 1 (2%) 1 (4%) 0 (0%)
Wrestling 1 (2%) 1 (4%) 0 (0%)
Diving 1 (2%) 1 (4%) 0 (0%)
Affected side Right (%) 26 (63%) 14 (52%) 12 (86%)
Affected Side Dominant (%) 28 (68%) 16 (59%) 12 (86%)
Bilateral (%) 1 (2%) 1 (4%) 0 (0%)
p=.0007
Vascular Surgery
Patient DemographicsAll
n=41nTOSn=27
PSSn=14
Age (mean) 19.0 19.0 18.8
Female (%) 18 (44%) 17 (63%) 1 (7%)
Sport (%)
Swimming 11 (27%) 11 (41%) 0 (0%)
Baseball 13 (33%) 4 (14%) 9 (65%)
Synchronized Swimming 2 (5%) 2 (7%) 0 (0%)
Volleyball 2 (5%) 1 (4%) 1 (7%)
Rowing 4 (10%) 3 (11%) 1 (7%)
Football 1 (2%) 0 (0%) 1 (7%)
Water Polo 5 (12%) 3 (11%) 2 (14%)
Weight Lifting 1 (2%) 1 (4%) 0 (0%)
Wrestling 1 (2%) 1 (4%) 0 (0%)
Diving 1 (2%) 1 (4%) 0 (0%)
Affected side Right (%) 26 (63%) 14 (52%) 12 (86%)
Affected Side Dominant (%) 28 (68%) 16 (59%) 12 (86%)
Bilateral (%) 1 (2%) 1 (4%) 0 (0%)
p=.04
p=.18
p = 1
Vascular Surgery
Treatment Outcomes-PSSAll TOS (n=41)
nTOS(n=27)
PSS(n=14)
Operative 32 (78%) 18 (66.7%) 14 (100%)
Non-Operative 9 (22%) 9 (33.3%) 0 (0%)
Thrombolysis 13 (31.7%) - 13 (92.9%)
Mean timing of Thrombolysis (days prior to surgery, range)
84 (2-730) - 84 (2-730)
Length of Symptoms before Treatment (mean, months)
7.811
(SURG-15.1/ NONOP-3)1.6
Return to Full Sport (%) 35 (85.4%) 22 (81.5%) 13 (92.9%)
Time to Pain Free (mean, months)
2.7 3.4 1.9
Time to Return Full Sport (mean, months)
4.6 4.4 4.7
Average Duration of Post-Op Anti-coagulation (months)
2.3 - 2.3
Vascular Surgery
Treatment Outcomes-PSSAll TOS (n=41)
nTOS(n=27)
PSS(n=14)
Operative 32 (78%) 18 (66.7%) 14 (100%)
Non-Operative 9 (22%) 9 (33.3%) 0 (0%)
Thrombolysis 13 (31.7%) - 13 (92.9%)
Mean timing of Thrombolysis (days prior to surgery, range)
84 (2-730) - 84 (2-730)
Length of Symptoms before Treatment (mean, months)
7.811
(SURG-15.1/ NONOP-3)1.6
Return to Full Sport (%) 35 (85.4%) 22 (81.5%) 13 (92.9%)
Time to Pain Free (mean, months)
2.7 3.4 1.9
Time to Return Full Sport (mean, months)
4.6 4.4 4.7
Average Duration of Post-Op Anti-coagulation (months)
2.3 - 2.3
• 64% with complete resolution• 36% with partial thrombus
burden
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Vascular Surgery
Treatment Outcomes-PSSAll TOS (n=41)
nTOS(n=27)
PSS(n=14)
Operative 32 (78%) 18 (66.7%) 14 (100%)
Non-Operative 9 (22%) 9 (33.3%) 0 (0%)
Thrombolysis 13 (31.7%) - 13 (92.9%)
Mean timing of Thrombolysis (days prior to surgery, range)
84 (2-730) - 84 (2-730)
Length of Symptoms before Treatment (mean, months)
7.811
(SURG-15.1/ NONOP-3)1.6
Return to Full Sport (%) 35 (85.4%) 22 (81.5%) 13 (92.9%)
Time to Pain Free (mean, months)
2.7 3.4 1.9
Time to Return Full Sport (mean, months)
4.6 4.4 4.7
Average Duration of Post-Op Anti-coagulation (months)
2.3 - 2.3
Vascular Surgery
Summary• High index of suspicion for TOS patients• Good prognosis for athletes
– 82% nTOS, 93% PSS – full return to sport
• Keys to success:– Multidisciplinary approach to TOS patients
• Sports medicine, orthopedics, physical therapy, team physicians, vascular surgeons, etc.
• Reporting standards and registries upcoming
Vascular Surgery
Thank You