Venous Thoracic Outlet Syndrome: Paraclavicular Approach

Robert W. Thompson, MD

horacic outlet syndrome (TOS) is a condition where the neurovascular structures leading to the arm are compressed in the space between the rst rib and scalene muscles. There are three clinical types of TOS: Neurogenic TOS, caused by compression of the brachial plexus between posterior rst rib, anterior scalene, and middle scalene, is often associated with repetitive motion injury related to occupational stresses and presents as local pain and hand and arm parasthesias. Arterial TOS, caused by compression of the artery, is often associated with a cervical rib that narrows this same triangle even more. These patients present with signs and symptoms of intermittent arm or hand ischemia. Provocative maneuvers that obliterate the radial pulse aid in establishing the diagnosis (although this nding is frequently present in patients without pathology). A subclavian bruit may also be heard. Because the subclavian artery and brachial plexus course through the same triangle, these forms of TOS often coexist. Thrombosis of the subclavian vein, also called effort thrombosis or Paget-Schroetter syndrome, is a relatively rare condition that affects young, active, otherwise healthy individuals.1 The underlying cause of effort thrombosis is compression and repetitive injury of the subclavian vein between the rst rib and overlying clavicle, anterior to the anterior scalene, and it is considered venous TOS. Venous TOS is quite distinct from neurogenic and arterial TOS, as pathophysiology, anantomy, clinical presentation, and functional consequences for the patient all differ widely from these.2-4 Conservative management of effort thrombosis, consisting of anticoagulation and arm elevation, was frequently used in the past. However, this approach rarely results in symptomfree use of the arm and imposes limitations unacceptable to most patients, and it is now evident that better outcomes are achieved by the early use of catheter-directed thrombolytic therapy.5 It is also apparent that there is a signicant risk of recurrent thrombosis following thrombolysis and anticoagulation alone, that balloon angioplasty does not provide durable treatment for residual subclavian vein stenosis, and that

placement of stents in the subclavian vein should be avoided.6 Surgical decompression of the thoracic outlet is therefore favored in most situations, typically within days to weeks of thrombolytic treatment. This can be accomplished by means of paraclavicular or transaxillary (see article by J. Freischlag in this issue) rst rib resection, or by internal jugular vein transposition to bypass a severely damaged vein (see article by M.J. Singh and C. Sura in this issue).

Indications
Effort thrombosis is caused in essentially every case by compression of the vein at the costoclavicular junction, and even when the thrombus has been removed by thrombolysis, recurrence is nearly universal without bony decompression. Placement of a stent in the nondecompressed vein is associated with fracture and rethrombosis as well; essentially any patient who is an acceptable surgical risk should be considered for decompression once full or partial patency has been restored. Our approach to venous TOS involves a comprehensive strategy based on paraclavicular thoracic outlet decompression.4 This approach combines the advantages of the supraclavicular exposure used for neurogenic and arterial forms of TOS with an infraclavicular incision that permits complete resection of the medial rst rib, as well as extensive exposure of the subclavian vein to permit vascular reconstruction.

Technique
Paraclavicular decompression for venous TOS begins with supraclavicular exposure (Fig 1). The patient is positioned supine under general anesthesia with the head of the bed elevated and the neck extended and turned to the opposite side. An operating table compatible with C-arm portable uoroscopy is recommended, because intraoperative venography with views of the shoulder and neck region is frequently utilized. A supraclavicular skin incision is made, and subplatysmal aps are developed to expose the scalene fat pad, which is moblized laterally (Fig 2). The phrenic nerve is identied coursing in a characteristic superolateral to inferomedial direction on the surface of the anterior scalene muscle. The anterior scalene muscle is circumferentially dissected at the level of its insertion on the rst rib, taking care to preserve the phrenic nerve and avoid injury to the subclavian 113

Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO. Address reprint requests to Robert W. Thompson, MD, Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, 5301 Queeny Tower, One Barnes-Jewish Hospital Plaza, Campus Box 8109, St. Louis, MO 63110. E-mail: thompson@wudosis.wustl.edu

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Figure 1 Paraclavicular decompression for venous TOS begins with supraclavicular exposure. The patient is positioned supine under general anesthesia with the head of the bed elevated 30, and the neck is extended and turned to the opposite side. An operating table compatible with C-arm portable uoroscopy is used, since intraoperative angiography with views of the shoulder and neck region is frequently utilized. The neck, chest, and affected upper extremity are prepped into the eld, with the arm wrapped in stockinette and held across the abdomen (this permits movement of the arm during the operation and provides access to the forearm and wrist when needed). The ipsilateral thigh is also included in the sterile eld to provide access to the greater saphenous vein. A transverse skin incision is made two ngerbreadths above the clavicle, beginning at the lateral edge of the sternocleidomastoid muscle, and following a skin crease parallel to the clavicle for approximately 8 cm. The incision is carried through the subcutaneous layer and subplatysmal aps are developed to expose the scalene fat pad. The small supraclavicular cutaneous nerves crossing the operative eld are divided if necessary to ensure adequate exposure. The omohyoid muscle is identied and its central portion is excised. (Color version of gure is available online.)

artery and brachial plexus (Fig 3). After division near the rib, the remaining muscle is lifted superiorly and detached from the underlying subclavian artery, brachial plexus nerve roots, and extrapleural fascia (Sibsons fascia). Scalene minimus muscle anomalies are often observed at this stage, characterized by muscle bers that pass between individual nerve roots of the brachial plexus, and these bers are also resected. Dissection of the anterior scalene muscle is carried superiorly to the level of its origin on the C6 transverse process, and the muscle is then divided and removed. In operations for venous TOS the brachial plexus nerve roots are mobilized pri-

marily to avoid injury, but in the event that they are found to be encircled by broinammatory scar tissue, a more complete external neurolysis is performed to help diminish the later development of neurogenic symptoms. The middle scalene muscle lies behind the roots of the brachial plexus, forming a broad oblique insertion on the lateral aspect of the rst rib (Fig 4). The mid-portion of the muscle is penetrated by the long thoracic nerve, which is often represented by two or three branches at this level rather than a single nerve. With the brachial plexus nerve roots gently retracted in a medial direction, the attachment of the middle

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Figure 2 One of the key elements in simplifying the supraclavicular exposure is proper mobilization and lateral reection of the scalene fat pad. This begins with detachment of the scalene fat pad at the lateral edge of the internal jugular vein and along its inferior edge behind the clavicle, followed by blunt dissection to progressively elevate the fat pad in a medial to lateral direction, exposing the surface of the anterior scalene muscle. The phrenic nerve is also identied at this stage, coursing in a superolateral to inferomedial direction on the surface of the anterior scalene muscle. The remaining inferior and superior attachments of the scalene fat pad are divided between ligatures to secure small blood vessels and lymphatics. On the left side, the thoracic duct is usually observed at the medial edge of the scalene fat pad coursing toward the junction of the internal jugular and subclavian veins, where it is gently ligated and divided. Lateral mobilization of the scalene fat pad continues until there is ample exposure of the anterior scalene muscle and phrenic nerve, the brachial plexus nerve roots passing posterior and lateral to the anterior scalene muscle, and the middle scalene muscle lying behind the brachial plexus. The lateral aspect of the rst rib is also palpated and visualized at this stage of the procedure, and the long thoracic nerve is often observed as it perforates the midportion of the middle scalene muscle and courses across the posterolateral aspect of the rst rib. The scalene fat pad is then held in position with several retraction sutures and kept moist during the remainder of the procedure. A. artery; M. muscle; N. nerve; V. vein. (Color version of gure is available online.)

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Figure 3 The anterior scalene muscle is circumferentially dissected at the level of its insertion on the rst rib, taking care to preserve the phrenic nerve, the subclavian artery, and the brachial plexus nerve roots. The anterior scalene muscle insertion is then sharply divided under direct vision using a curved Mayo scissors, avoiding use of the cautery to prevent inadvertent thermal injury to the adjacent structures. The remaining anterior scalene muscle is lifted superiorly and detached from the underlying subclavian artery, brachial plexus nerve roots, and extrapleural fascia (Sibsons fascia). Scalene minimus muscle anomalies are often observed at this stage, characterized by muscle bers that pass between individual nerve roots of the brachial plexus, and these bers are also resected. Dissection of the anterior scalene muscle is carried superiorly to the level of its origin on the C6 transverse process, which is easily palpated within the upper aspect of the operative eld, and the muscle is then divided and removed. At this stage in the procedure, it is now possible to identify each of the ve nerve roots comprising the brachial plexus (C5, C6, C7, C8, and T1) throughout their course within the thoracic outlet, as well as to identify various aberrant brous bands, ligaments, or fascial attachments that may contribute to neurovascular compression. In operations for venous TOS the brachial plexus nerve roots are mobilized primarily to avoid injury, but in the event that they are found to be encircled by broinammatory scar tissue, a more complete external neurolysis is performed to help diminish the later development of neurogenic symptoms. M. muscle; N. nerve. (Color version of gure is available online.)

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Figure 4 The middle scalene muscle lies behind the roots of the brachial plexus, forming a broad oblique insertion on the lateral aspect of the rst rib. The mid-portion of the muscle is penetrated by the long thoracic nerve, which is often represented by two or three branches at this level rather than a single nerve. With the brachial plexus nerve roots gently retracted in a medial direction, the attachment of the middle scalene muscle is carefully divided from the top of the rst rib using a cautery and periosteal elevator. The portion of the middle scalene muscle lying anterior to the long thoracic nerve is excised, and any remaining middle scalene muscle is detached from the posterior surface of the rst rib (it is notable that cervical rib anomalies may be encountered at this stage, since they arise within the same tissue plane as the middle scalene muscle, allowing ample exposure for resection at this point in the procedure). While maintaining gentle medial retraction of the brachial plexus (particularly the C8 and T1 nerve roots) the intercostal muscles along the posterolateral aspect of the rst rib are next divided. The tip of a right-angle clamp is passed underneath the posterior neck of the rst rib and the rst intercostal nerve is pushed inferiorly away from the bone while the remaining intercostal muscle is detached. A modied Stille-Giertz rib cutter is applied to divide and excise a small segment of the posterior rst rib. A Kerrison bone rongeur is used to smooth the posterior end of the rib to a level immediately medial to the course of the T1 nerve root, and it is sealed with bone wax. The free proximal end of the rst rib is elevated, and by passing a ngertip underneath the rib toward its anterior aspect, the additional extrapleural fascia and intercostal muscle attachments are divided to the level of the anterior scalene tubercle. Although in operations for neurogenic and arterial TOS the rst rib is next divided just medial to the scalene tubercle and removed, in operations for venous TOS the anterior portion of the rst rib is not divided at this stage and the procedure is continued by moving to the infraclavicular portion of the operation. M. muscle; N. nerve. (Color version of gure is available online.)

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Figure 5 Complete resection of the medial portion of the rst rib, which contributes most to subclavian vein compression in venous TOS, cannot be performed solely through the supraclavicular approach. To accomplish this, a second transverse skin incision is made one ngerbreadth below the medial clavicle, extending laterally from the edge of the sternum for approximately 6 cm. The incision is carried to the level of the fascia and then in a plane separating, but not dividing, the upper and middle portions of the pectoralis major muscle. The cartilaginous portion of the rst rib is identied by palpation, facilitated by applying downward pressure to the divided posterior segment of the rst rib with a nger placed within the supraclavicular incision. This places the attachments between the medial rst rib and clavicle under tension, allowing the medial portion of the rst rib to be dissected from its soft tissue attachments through the infraclavicular incision. V. vein. (Color version of gure is available online.)

scalene muscle is carefully divided, the portion lying anterior to the long thoracic nerve excised, and any remaining bers detached from the posterior surface of the rst rib. While maintaining gentle medial retraction of the brachial plexus (particularly the C8 and T1 nerve roots) the intercostal muscles along the posterolateral aspect of the rst rib are next divided and a small posterior segment of the rst rib divided. Complete resection of the anteromedial portion of the rst rib, which contributes most to subclavian vein compression in venous TOS, cannot be performed solely through the supraclavicular approach. To accomplish this, a second transverse skin incision is made below the clavicle, extending laterally from the edge of the sternum for approximately 6 cm (Fig 5). The cartilaginous portion of the rst rib is identied by palpation, facilitated by applying downward pressure to the divided posterior segment of the rst rib with a nger placed within the supraclavicular incision. The subclavius muscle tendon, the costoclavicular ligament, and the muscles of the rst intercostal space are divided under direct vision extending to the lateral edge of the sternum (Fig 6), and the cartilaginous portion of the rst rib is then divided adjacent to the sternum and the rst rib removed from the operative eld. The subclavian vein is identied as it passes from underneath the distal clavicle, carefully separated from the subclavius muscle, and this muscle and its tendon resected. Further exposure of the subclavian vein is undertaken by dissection through the supraclavicular exposure. The internal jugular vein is then fully exposed several centimeters

superior to its junction with the subclavian vein, and the innominate vein exposed for several centimeters into the upper mediastinum. The course of the phrenic nerve into the upper mediastinum is also noted, to identify situations where it passes anterior to the subclavian vein and thereby contributes to venous obstruction (in this circumstance, the accessory phrenic nerve is mobilized away from the subclavian vein but not divided). At this stage in the procedure the pathological changes in the central portion of the subclavian vein can be fully assessed visually and by digital palpation (Fig 7). Any residual scar tissue surrounding the proximal portion of the subclavian vein is therefore completely excised (circumferential external venolysis), often resulting in re-expansion of the previously constricted segment of the vein. If there is no focal reduction in the diameter of the vein after complete external venolysis, if the vein is soft and easily compressible to palpation, and if the vein shows evidence of rapid lling and emptying with respiratory variation, it is likely that no further venous reconstruction is necessary. In this event, attention is turned to performance of an intraoperative venogram to conrm that the subclavian vein is widely patent. In our experience, this is the case in approximately 50% of patients with venous TOS, even in those with long-segment stenosis before operation. When external venolysis alone is insufcient to alleviate subclavian vein obstruction or when intraoperative venography demonstrates a residual stenosis despite the apparent success of external venolysis, additional venous re-

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Figure 6 The subclavius muscle tendon, the costoclavicular ligament, and the muscles of the rst intercostal space are divided under direct vision extending to the lateral edge of the sternum. The cartilaginous portion of the rst rib is then divided adjacent to the sternum using the cutting cautery and/or curved Mayo scissors, and the rst rib is removed from the operative eld as a single specimen. The subclavian vein is identied as it passes from underneath the distal clavicle, as visualized through the lateral portion of the infraclavicular incision. The vein is carefully separated from the subclavius muscle moving toward the medial aspect of the surgical eld, and any collateral vein branches that enter the subclavian vein are ligated and divided. Once the vein has been sufciently separated from underneath the subclavius muscle, the muscle and its tendon are resected. Further exposure of the subclavian vein is undertaken by dissection through the supraclavicular exposure. This is initiated along the lateral aspect of the subclavian vein and continued medially toward the junction of the subclavian and internal jugular veins to form the brachiocephalic (innominate) vein. It is important to identify a large collateral vein that consistently arises from the subclavian vein immediately underneath the clavicle. Once this collateral vein has been satisfactorily ligated and divided the subclavian vein will fall away from the clavicle, allowing complete exposure to its junction with the internal jugular and innominate veins. The internal jugular vein is then fully exposed several centimeters superior to its junction with the subclavian vein, and the innominate vein is exposed for several centimeters into the upper mediastinum. The course of the phrenic nerve into the upper mediastinum is also noted, to identify situations where it passes anterior to the subclavian vein and thereby contributes to venous obstruction (in this circumstance, the accessory phrenic nerve is mobilized away from the subclavian vein but not divided). (Color version of gure is available online.)

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Figure 7 At this stage in the procedure the pathological changes in the central portion of the subclavian vein can be fully assessed visually and by digital palpation. Although there may be no evidence of thrombotic luminal obstruction if the patient had undergone successful thrombolysis before surgery, the subclavian vein is typically found to harbor a focal area with brous wall thickening resulting from chronic repetitive injury. Any residual scar tissue surrounding the proximal portion of the subclavian vein is therefore completely excised (circumferential external venolysis), often resulting in re-expansion of the previously constricted segment of the vein. Indeed, if there is no focal reduction in the diameter of the vein following complete external venolysis, if the vein is soft and easily compressible to palpation, and if the vein shows evidence of rapid lling and emptying with respiratory variation, it is likely that no further venous reconstruction is necessary. In this event, attention is turned to performance of an intraoperative venogram to conrm that the subclavian vein is widely patent. In our experience, this is the case in approximately 50% of patients with venous TOS, even in those with long-segment stenosis before operation. When external venolysis alone is insufcient to alleviate subclavian vein obstruction, or when intraoperative venography demonstrates a residual stenosis despite the apparent success of external venolysis, additional venous reconstruction is performed. A continuous infusion of Dextran is started along with systemic anticoagulation using intravenous heparin, and clamp control is obtained of the distal subclavian and internal jugular veins. A pediatric Satinsky clamp is passed around the upper portion of the innominate vein, taking care not to damage posterior collateral veins within the mediastinum and to exclude the phrenic nerve. A longitudinal venotomy is created along the superior aspect of the subclavian vein and the lumen inspected. If there is only mild focal stenosis of the subclavian vein and the luminal surface is smooth and free of thrombus and/or irregularity (after resection of any minimal intimal webs), a simple patch angioplasty is performed using greater saphenous vein harvested from the thigh (or alternatively, a segment of bovine pericardium). The patch angioplasty is constructed to span the entire affected area of the subclavian vein with an extension onto the lateral aspect of the internal jugular vein (or inferiorly along the innominate vein), to avoid obstructive kinking in the upright position. When dense brosis remains within the wall of the subclavian vein despite external venolysis, or when another obvious abnormality is present on inspection of the opened vein, the affected segment of the subclavian vein is replaced by interposition bypass. The intervening segment of the native subclavian vein is excised, and an interposition graft is constructed using an end-to-end anastomosis to the unaffected distal subclavian vein and an end-to-side anastomosis to the lateral aspect of the jugular-subclavian junction. Because the caliber of the saphenous vein is too small to match the subclavian vein in most patients, the harvested segment of saphenous vein is opened longitudinally and a panel graft is created to provide a conduit with twice the diameter of the native saphenous vein (in the event that the saphenous vein cannot be used, a conduit of similar size can be constructed from bovine pericardium). Finally, intraoperative venography is used to conrm satisfactory subclavian vein reconstruction, typically performed through the cephalic vein in the distal forearm. Our operative approach also includes frequent construction of a temporary radiocephalic arteriovenous (AV) stula between the end of the distal cephalic vein and the side of the radial artery, used as an adjunct to increase upper extremity venous blood ow during the rst several months after operation. On completion of the procedure, the pleural apex is opened to facilitate postoperative drainage of uid into the chest cavity. A #19 Blake closed-suction drain is placed within the superior operative eld lying posterior to the brachial plexus, with its tip extending into the pleura, and the scalene fat pad is restored to its anatomic position and held in place with several tacking sutures. The platysma layer is closed with interrupted sutures and the skin is closed with a subcuticular stitch. (Color version of gure is available online.)

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construction is performed. If there is only mild focal stenosis of the subclavian vein and the luminal surface is smooth and free of thrombus and/or irregularity (after resection of any minimal intimal webs), a simple patch angioplasty is performed using greater saphenous vein harvested from the thigh (or alternatively, a segment of bovine pericardium). When dense brosis remains within the wall of the subclavian vein despite external venolysis, or when another obvious abnormality is present on inspection of the opened vein, the affected segment of the subclavian vein is replaced by interposition bypass or IJ turndown performed (see article by M.J. Singh and C. Sura in this issue). Finally, intraoperative venography is used to conrm satisfactory subclavian vein reconstruction, typically performed through the cephalic vein in the distal forearm. Our operative approach also includes frequent construction of a temporary radiocephalic arteriovenous (AV) stula between the end of the distal cephalic vein and the side of the radial artery, used as an adjunct to increase upper extremity venous blood ow during the rst several months after operation. Postoperative care includes ample use of pain medications, muscle relaxants, and anti-inammatory agents. Chest radiographs are obtained for several days to monitor any collection of pleural uid, which typically resolves over the course of the rst week. The expected hospital stay is 5 to 6 days, with the closed-suction drain removed 7 to 10 days after operation. Inpatient physical therapy is started the day after operation to maintain range of motion, with postoperative rehabilitation then overseen by a physical therapist with expertise in the management of TOS, usually in conjunction with a physical therapist located near the patient; no restrictions are placed on upper extremity activity beyond 12 weeks after operation. Therapeutic anticoagulation is initiated several days after operation with intravenous heparin (with or without the addition of aspirin or clopidogrel), followed by low molecular weight heparin and conversion to warfarin. Anticoagulant and antiplatelet agents are maintained until 12 weeks after operation then discontinued. For patients with venous TOS and a patent AV stula, follow-up imaging stud-

121 ies are not performed in the absence of any symptoms of venous obstruction. These individuals then undergo outpatient ligation of the AV stula under local anesthesia 12 weeks after the primary operation, at which time follow-up contrast venography can also be performed.

Conclusions
In a surgical experience that now exceeds 100 procedures using this approach, we have been able to offer operative decompression to all patients with symptomatic venous TOS or recent effort thrombosis, regardless of the interval between initial diagnosis and referral, previous treatment, or adverse ndings on contrast venography. A recent review of our results in competitive athletes with effort thrombosis, a particularly challenging population, veries that this strategy of surgical treatment can result in excellent early and long-term outcomes.7 This has led us to conclude that operative procedures based on paraclavicular exposure provide the most versatile, comprehensive, and safe approach to the treatment of venous TOS.

References
1. Hughes ESR: Venous obstruction in the upper extremity (Paget-Schroetters syndrome). Int Abstracts of Surg 88:89-127, 1949 2. Sanders RJ: Thoracic Outlet syndrome: A common sequelae of neck injuries. Philadelphia: J. B. Lippincott Company, 1991 3. Urschel HC Jr: The transaxillary approach for treatment of thoracic outlet syndromes. Semin Thorac Cardiovasc Surg 8:214-220, 1996 4. Thompson RW, Petrinec D, Toursarkissian B: Surgical treatment of thoracic outlet compression syndromes. II. Supraclavicular exploration and vascular reconstruction. Ann Vasc Surg 11:442-451, 1997 5. Rutherford RB: Primary subclavian-axillary vein thrombosis: The relative roles of thrombolysis, percutaneous angioplasty, stents, and surgery. Semin Vasc Surg 11:91-95, 1998 6. Lee JT, Karwowski JK, Harris EJ, et al: Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg 43:1236-1243, 2006 7. Melby SJ, Vedantham S, Narra VR, et al: Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome). J Vasc Surg 47:809820, 2008

Venous Thoracic Outlet Syndrome: Transaxillary Approach

Julie Freischlag, MD

s discussed in the prior article, compression at the level of the thoracic outlet can affect the brachial plexus, subclavian artery, or axillosubclavian vein. The venous form of TOS, also known as Paget-Schrotter syndrome, most often occurs in athletes who have suffered an acute effort thrombosis of the axillosubclavian vein.1 These patients are typically males in their late 20s to early 30s who have participated in some form of strenuous physical activity with the affected arm. They often present emergently with an acutely swollen upper extremity that has a bluish discoloration. A duplex scan is performed indicating a partial or complete thrombosis of the subclavian and/or axillary vein. A venogram and catheter directed thrombolytic therapy may be used to recanalize the vein. These patients are then maintained on anticoagulation therapy and rst rib resection is considered days to weeks later to prevent recurrent thrombosis of the vein. The pathophysiology of effort thrombosis is compression of the vein between the rst rib and clavicle, with substantial effects also because of the anterior scalene behind the vein and subclavius muscle between the clavicle and rst rib. These muscles have the potential to scar or hypertrophy, contributing to compression. Further background, indications for decompression, and technique of and results after the paraclavicular approach were discussed in the previous article. Venous TOS is a condition of the anterior rst rib and subclavius muscle; for this reason, many clinicians and investigators believe that the transaxillary approach, which allows excellent exposure of the anterior structures, is best suited for patients with this condition.

Operative Technique
The portion of the thoracic inlet of concern when dealing with venous compression is the junction of the rst rib and clavicle; the anterior scalene lies behind the vein (Fig 1). The subclavius muscle occupies the angle between the clavicle

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Address reprint requests to Julie Freischlag, MD, William Stewart Halsted Professor and Chair, Department of Surgery, Johns Hopkins University School of Medicine, East Baltimore Campus, Ross 759, Baltimore, MD 21205. E-mail: Jfreisc1@jhmi.edu

and rst rib and may also compress the subclavian vein. Many prefer the transaxillary approach for venous TOS because of the superb visualization of the anterior structures and effectiveness of decompression. After positioning in a lateral decubitus position, the patient is prepped from the neck to beyond the nipples and an adjustable arm support (Machleder retractor) is attached to the OR bed (Fig 2), which allows elevation of the arm to facilitate exposure of the thoracic outlet. Alternatively, the arm can be elevated by suspension over an orthopedic shower curtain (Rochester) or an assistant can be tasked with this job. An incision is made in the axilla bounded by the pectoralis major and latissimus dorsi, and the chest wall exposed (Fig 3). Finger dissection is used to reach the rst rib as it approaches the clavicle, which can seem quite high to the neophyte. The rst rib is identied by noting the insertion of the anterior scalene coursing between the artery and vein (Fig 4), which is divided at its insertion (the phrenic nerve is medial at this point and not usually seen). The lower edge of the rib is cleared and the pleura pushed down. A hypertrophied subclavius muscle may play an important role in contributing to venous TOS. This muscle is sharply divided with a pair of scissors; care is taken not to injure the vein by keeping the tips of the scissors directed toward the rib surface (Fig 5). This maneuver also exposes a greater length of rst rib anteriorly for resection. At this point the rib is divided anteriorly (Fig 6), and further resection accomplished using a rongeur. Resection posteriorly is the nal step, once full exposure has been achieved. The bone edges should be fairly smooth and there should be no impingement on the neurovascular structures at this point (Fig 7). Saline is poured in the axillary cavity and the patient is given several positive pressure ventilations to check for defects in the parietal pleura. If a pneumothorax is present, a 12 Fr chest tube is inserted in the second intercostal space through a separate stab incision. The arm is then lowered and the axillary soft tissue is closed in two layers. Patients should not resume anticoagulation until 3 days after surgery to lessen the chance of bleeding complications, such as a chest wall hematoma or hemothorax. Two weeks postoperatively, patients undergo follow-up venogram and any areas of venous stenosis can now be dilated in the absence of extrinsic compression.5 If no abnormalities are noted and the patient is asymptomatic,

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Figure 1 Anatomically, the thoracic outlet is bounded by the rst rib inferiorly and the clavicle medially, and spans the distance from the third portion of the subclavian artery to the axillary artery. Originating from the cervical spine (here shown detached), the anterior and middle scalene muscles insert onto the rst rib, forming the scalene triangle within the thoracic outlet. It should be stressed that the different forms of TOS have different structures compressing them: the subclavian artery and brachial plexus run through the triangle formed by anterior scalene, middle scalene, and rst rib posteriorly, and the axillary-subclavian vein runs through the triangle formed by the rst rib, anterior scalene, and clavicle (actually subclavius muscle underlying the bone itself) anteriorly. m. muscle; a. artery; v. vein.

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Figure 2 Patients that have been diagnosed with TOS and are considered to be surgical candidates can undergo either a transaxillary or supraclavicular approach to the thoracic outlet. The transaxillary approach is preferred for venous TOS because of the anatomical visualization and effectiveness of decompression. The patient undergoes general anesthesia with a short-acting neuromuscular blockade that allows for safer dissection around the brachial plexus. After positioning in a lateral decubitus position, the patient is prepped from the neck to beyond the nipples and an adjustable arm support (Machleder retractor) is attached to the OR bed. This device allows for elevation of the arm to facilitate exposure of the thoracic outlet. Before placement on the support, the arm is padded well to prevent injury to the median and ulnar nerves as they cross the elbow. The lateral edges of the latissimus dorsi and pectoralis major muscles are identied and the skin is incised between these muscles on the lower border of the axillary hair line.

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Figure 3 The soft tissue of the axilla is divided with electrocautery to reach the imsy areolar tissue supercial to the chest wall. Gentle nger dissection in an anterior and cephalad direction is used to reach the rst rib as it approaches the clavicle. At this point a self-retaining retractor is placed to separate the skin and supercial soft tissue and the Machleder arm elevator is raised to gain exposure to the thoracic outlet.3 The rst rib is identied and the lower edge of the rib is bluntly cleared of its intercostal muscle attachments using a at periosteal elevator (initiating this plane is facilitated by careful division of the intercostal muscles at the inferior border of the rst rib by electrocautery). The rst rib is lifted off of the underlying pleura by gently sliding a small periosteal elevator between these structures. The pleura is pushed away from the rib and this mobilization should extend from behind the brachial plexus posteriorly to in front of the subclavian vein anteriorly. A periosteal elevator is also used to scrape scalene medius bers from the superior surface of the rst rib. Sharp dissection of the scalene medius muscle is avoided because the long thoracic nerve courses adjacent to this muscle and may be inadvertently divided.

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Figure 4 The tissue overlying the brachial plexus, subclavian artery and vein, and scalene muscles are swept away with a Kitner dissector. The anterior scalene muscle must be clearly visualized between the subclavian artery and vein, and appears to arise from deep in the wound up between the vessels to insert on the rst rib. A right-angled clamp is brought behind the anterior scalene muscle, lifting it away from the neighboring artery. The muscle is cut with scissors leaving as much length attached to the rib as possible. This maneuver may need to be repeated to divide the entire muscle safely. a. artery; v. vein.

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Figure 5 The subclavius muscle, which has a crescent-shaped tendonous attachment on the rst rib adjacent to the subclavian vein, is sharply divided with a pair of scissors. Care is taken not to injure the vein by keeping the tips of the scissors directed toward the rib surface. A hypertrophied subclavius muscle may play an important role in contributing to venous TOS. Division of the subclavius muscle provides greater length of rst rib anteriorly for resection. m. muscle; v. vein.

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Figure 6 A bone cutter is placed anteriorly and the rst rib is divided adjacent to the subclavian vein. The posterior division of the rib occurs once the rest of the rib has been mobilized, which helps prevent injury to the brachial plexus by allowing optimal visualization. The rib cutter is gently applied to the rib just anterior to the brachial plexus. The rib is always cut in front of the nerve, so that posterior nerve roots are not unintentionally damaged. The remainder of the rib ends are then trimmed using a bone rongeur. The nerve is pushed away from the bone and protected with a Roos retractor as the rib is rongeured posteriorly.4 a. artery; v. vein.

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Figure 7 The bone edges should be fairly smooth and there should be no impingement on the neurovascular structures at this point. Saline is poured in the axillary cavity and the patient is given several positive pressure ventilations to check for defects in the parietal pleura. If a pneumothorax is present, a 12 Fr chest tube may be inserted in the second intercostal space through a separate stab incision, although if the patient is young and healthy simple suction drainage through the wound is often well tolerated. The arm is then lowered and the axillary soft tissue is closed in two layers. A chest radiograph is obtained in the recovery area.

anticoagulation is stopped.2 Completely thrombosed veins may spontaneously open after rib resection while the patient is anticoagulated. In these instances, the patients continue oral anticoagulation for 3 months at which time a repeat duplex scan is performed. Following rst rib resection, physical activity is restricted for 2 weeks and the patients arm is supported in a sling. After 2 weeks, physical therapy is instituted, focusing on increased range of motion, stretching, and soft tissue massage. A patients compliance with physical therapy plays a key role not only for a successful recovery, but also for minimizing the

risk of recurrent injury. Scar tissue thickens and remodels for approximately 2 years after surgery, and its effects on the thoracic outlet can be minimized with physical therapy.6 For this reason, physical therapy and rehabilitation have become important for both functional recovery and avoiding recurring symptoms.

References
1. Angle N, Gelabert HA, Farooq MM, et al: Safety and efcacy of early surgical decompression of the thoracic outlet for Paget-Schoretter syndrome. Ann Vasc Surg 15:37-42, 2001

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2. Caparrelli DJ, Freischlag J: A unied approach to axillosubclavian venous thrombosis in a single hospital admission. Semin Vasc Surg 18:153-157, 2005 3. Machleder HI: Thoracic outlet syndromes: New concepts from a century of discovery. Cardiovasc Surg 2:137-145, 1994 4. Roos DB: Transaxillary approach for rst rib resection to relieve thoracic outlet compression syndrome. Ann Surg 163:354, 1966

J. Freischlag
5. Perler BA, Mitchell SE: Percutaneous transluminal angioplasty and transaxillary rst rib resection. A multidisciplinary approach to the thoracic outlet syndrome. Am Surg 52:485-488, 1986 6. Green RM, McNamara J, Ouriel K: Long-term follow-up after thoracic outlet decompression: An analysis of factors determining outcome. J Vasc Surg 14:739-746, 1991

Endovenous Saphenous and Perforator Vein Ablation

Michael J. Singh, MD, and Cheryl Sura, LPN, RVT

enous insufciency is a common disorder. Approximately 80 million people are affected; it is estimated that 30% of women and 10% to 20% of men have varicose veins. Supercial varicosities are often caused by venous reux because of failure of the valves in the saphenous vein and at the saphenofemoral junction. This reux increases supercial venous pressure, which then leads to the development of varicose veins. Transmission of pressure to the deep system via incompetent perforators (or intrinsic deep reux) leads to classic venous insufciency, which is manifested by ankle edema, leg fatigue, aching, purities, stasis dermatitis, lipodermatosclerosis, or ulceration. In a relatively short period of time, endovenous radiofrequency ablation has emerged as the standard of care for managing supercial and perforator vein reux. For those who have failed conservative treatment, endovenous ablation has been shown to be an effective and efcient procedure for managing venous insufciency. Patients require minimal time for recovery and pain is marked reduced when compared with traditional surgical techniques offered for venous insufciency. Endovenous laser ablation has similar success rates, but tends to have a higher incidence of postoperative ecchymosis, thrombophlebitis, and pain that makes it a less attractive option.1-4

Finally, although not a medical requirement, most insurance companies will not provide coverage of venous procedures unless the patient has been compliant with a nonoperative treatment regimen for at least 3 months; this includes the use of compression stockings, leg elevation, exercise, weight loss, and anti-inammatory medications.

Preoperative Evaluation
A preprocedure duplex ultrasound examination is initially performed to document reux in the system to be treated. This is also required to determine whether the patient has the proper anatomy for the procedure as discussed above; it should assess patency of the entire lower extremity venous system (deep, supercial, and perforator). Routine hematologic or other laboratory studies are not typically performed, unless indicated by the health history (eg, anticoagulation therapy would require checking an INR).

Procedure Technique
Endovenous procedures can be performed today in the ofce setting, an outpatient surgical center, or operating room. In most circumstances today, most procedures are performed in the ofce, in part because of insurance company incentives. Using an oral anxiolytic combined with generous local tumescent anesthesia, patient comfort, safety, and acceptance are excellent.6-7 Patients are premedicated with two 5 mg doses of diazepam, the rst is administered 1 h before the procedure and the second just before initiating the endovenous procedure. The patient is placed in reverse Trendelenberg position (5-10), which dilates the venous system and aids percutaneous access. The knee is slightly exed and externally rotated. After sterile preparation, the greater saphenous vein (GSV) is marked, mapped, and measured with a portable ultrasound machine. A probe frequency of 7.5 MHZ or greater is benecial during these procedures as a shallow depth of eld is helpful to optimize vessel resolution. Areas of angulation, tortuosity, large branch vessels, and aneurismal dilation are marked on the skin overlying the vein. The optimal access site is determined by ultrasound imaging and often is below the level of the knee. Percutaneous ultrasound guided access is obtained using a micropuncture needle (Fig 1), and through a 7 Fr sheath the radiofrequency ablation catheter (ClosureFast; VNUS Medical Technologies, San Jose, CA) is advanced to the saphenofemoral junction (SFJ) (Fig 2). In some cases, venous tortuousity or prior phlebitis may not permit catheter advancement. 131

Indications
Radiofrequency ablation (RFA) is appropriate for virtually any saphenous vein, although certain anatomic criteria must be present. Most patients will have a Clinical Etiology Anatomy Pathophysiology classication score of 2 to 6.5 Obviously, the rst requirement is that reux exists in the saphenous vein. This is determined using duplex ultrasonography with direct visualization of retrograde ow through incompetent valves in response to gravity, compression, or Valsalva maneuver. Starting at the groin of the symptomatic leg, a longitudinal view of the common femoral vein is obtained, with blue assigned as antegrade venous ow. The patient performs a valsalva maneuver and the color-ow and Doppler spectral changes are observed. The same steps are followed for the supercial femoral vein, saphenofemoral junction and both saphenous veins (greater and small).

Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY. Address reprint requests to Michael J. Singh, MD, Division of Vascular Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: Michael_Singh@urmc.rochester.edu

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Figure 1 Lidocaine (1%) is locally inltrated at the chosen site. Percutaneous ultrasound guided access is obtained using a micropuncture catheter system. Using B-mode imaging, the vein is centered on the transducer in a longitudinal plane (parallel to the vein). The access needle is positioned bevel up at a 60 angle and the anterior wall of the vein penetrated. A longitudinal image provides excellent visualization of the tissue planes and anterior vessel wall as the needled is advanced. After access is obtained, the micropuncture system is exchanged for an 11-cm 7 Fr introducer sheath using the modied Seldinger technique. Smaller veins and veins in spasm can be challenging. Access in these situations is aided by the placement of an elastic tourniquet proximal to the access site. Alternatively, a small surgical cut down (3-4 mm) will provide direct visualization of the vein and elevation with a blunt tipped stab phlebectomy hook utilized. v. vein.

These situations are handled by straightening the vein with external compression using the skin stretch maneuver and ultrasound imaging. Alternatively, an over-the-wire technique using a 0.018 or 0.025 angled hydrophilic guide wire will aide the passage of the catheter. Longitudinal imaging with the ultrasound probe will best dene the location of the epigastric vein and SFJ in relation to the catheter tip. The tip of the catheter is drawn back and positioned 20 mm distal to the SJF and distal to the supercial epigastric vein (Fig 3), which is important to maintain ow through the SFJ after saphenous closure. Tumescent anesthesia, a large-volume, low-concentration Lidocaine solution (0.10-0.25%) is commonly used for endovenous ablation. This is a combination of 50 mL 1% Lidocaine with epinephrine and 5 mL of sodium bicarbonate in 500 mL of 0.9% normal saline. The tumescent inltration is

extremely important for procedural success: it compresses the vein around the catheter for improved contact, increases the distance from the skin to the vein to minimize (ideally eliminate) thermal skin injury, and eliminates pain. Adequate tumescent inltration begins at the access site and extends beyond the catheter tip. The 22-gauge spinal needle is positioned in the perivenous fascia and inltration is guided by ultrasound imaging. The goal is to circumferentially compress the vein within the perivascular compartment, thus creating a halo around the catheter and vein. To protect the skin, tumescent inltration should separate the skin and catheter by at least 10 mm. The radiofrequency catheter tip position (20 mm distal to the SFJ) is conrmed by ultrasound and direct pressure along the course of the vein is applied. The procedure is initiated as per recommended protocol. The catheter has a

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Figure 2 Percutaneous venous access is obtained at or below the level of the knee. The new 7 Fr radiofrequency ablation catheter (ClosureFast; VNUS Medical Technologies) comes in two lengths (60 cm and 100 cm). The catheter length is measured ex vivo and the catheter advanced to the saphenofemoral junction (SFJ). a. artery; v. vein.

7 cm long heater element that reaches 120C for 20 s at a time; the tip is then drawn back at 6.5 cm increments and the cycle repeated. At the completion of the procedure, a nal duplex scan is performed to conrm patency of the epigastric vein, SFJ, and deep venous system. The rate of immediate GSV occlusion at the SFJ is almost 100%; ultrasound imaging will show a thickened vein wall with absence of a ow lumen.

Bilateral GSV ablation can easily be performed. Doubling the amount of tumescent solution is necessary; this has been shown to be safe at a concentration of 35 mg/kg. During bilateral VNUS Closure procedures, percutaneous ultrasound guided GSV access is obtained in each leg before the catheter insertion. This technique minimizes access problems in the contralateral leg because of vasospasm. The more tortuous GSV is always ablated rst, which allows the use of the over-the-wire catheter advance-

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Figure 3 Longitudinal imaging with the ultrasound probe will best dene the location of the epigastric vein and SFJ in relation to the catheter tip. The tip of the catheter is drawn back and positioned 20 mm distal to the SJF and distal to the supercial epigastric vein, and the locking donuts are advanced to secure the catheter position. Preservation of the SEV is of the utmost importance as it maintains ow through the SFJ after closing the GSV. a. artery; v. vein.

ment technique. Often the catheter lumen occludes during the rst Closure procedure that prevents use of the over-the-wire technique during the second procedure. Short saphenous vein (SSV) ablation is similar to that of the greater saphenous vein. If performed simultaneously the GSV is addressed rst, followed by repositioning the patient in the prone position. The SSV is marked, mapped, and measured. Percutaneous access is obtained in the mid to distal calf and the catheter inserted and positioned 20 mm below the saphenopopliteal junction. Tumescent anesthesia is inltrated and the procedure started. Follow-up imaging and instructions are identical to the GSV ablation. After the procedure, access site(s) are covered with a sterile bandage and thigh high 20 to 30 mm Hg compression stockings applied and left in place for 24 h. A follow-up Duplex scan is performed 3 to 5 days after the procedure to document absence of thrombus central to the SFJ or SPJ as appropriate.

of the deep venous system. RF perforator ablation can effectively treat incompetent perforator veins with minimal morbidity and a closure rate of 70% to 80%.8

Results
Since its inception in 1998, it is estimated that over 250,000 radiofrequency ablation procedures have been performed. As with many industry-driven technologic procedures, hard data are somewhat lacking. Early trials demonstrated an unacceptably high rate of cutaneous skin burns, but this problem has largely been eliminated with the technique of tumescent anesthesia. An immediate closure rate of approximately 85% is commonly quoted, but long-term follow-up is poor. When subjected to Kaplan-Meyer analysis, most failures (recanalization) occur within the rst year or so, and long-term outcome after this is generally satisfactory. There is some data suggesting that endovenous laser therapy has a slightly better closure rate than radiofrequency ablation, but these data are derived using the rst-generation RFA device. The secondgeneration device, ClosureFast (VNUS Medical Technologies), has shortened pullback times to approximately 3 min and is associated with 100% closure at 6 months in preliminary studies.9-11

Perforator Vein Ablation

The traditional surgical Linton procedure has been replaced by subfascial endoscopic perforator surgery (SEPS, see article by Iafrati MD in this issue) for treatment of incompetent perforators, and in turn SEPS may be soon replaced by percutaneous perforator ablation. The current treatment method is a modication of GSV radiofrequency ablation, and can be performed as a stand-alone procedure or along with GSV ablation (Fig 4). A completion duplex scan should be performed to conrm successful perforator closure and patency

Summary
Endoluminal radiofrequency ablation has many advantages over the traditional high ligation and stripping procedures. In a short period of time, it has become a viable alternative and

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Figure 4 The leg is positioned and the perforator veins marked and mapped with ultrasound imaging; distance from the medial malleous is documented to guide follow-up imaging. The leg is prepped and draped and the perforator vein longitudinally visualized. Placing the transducer parallel to the perforator vein and using B-mode imaging improves visualization and simplies vessel access. One percentage Lidocaine is locally injected and a 12 gauge angiocath inserted at a 60 angle. Intraluminal placement is conrmed by noting dimpling of the anterior vessel wall and aspiration of blood. The RFS catheter is inserted and beaded catheter tip advanced to a subfascial segment of the perforator vein. The nal position of the tip should be 5 mm from the deep system, which reduces the incidence of deep vein thrombosis. Catheter placement is conrmed and tumescent anesthesia locally administered. Direct pressure is applied over the catheter and vein using the ultrasound probe. A four-quadrant closure technique at 85 degree Celsius is used. To ensure adequate wall contact, the closure is performed over 4 min (1 min per quadrant). Impedance levels should range from 150 to 350 Ohms; levels over 400 Ohms suggest extraluminal catheter placement. After the 4-min cycle is complete, the catheter is pulled back 5 to 10 mm and a second 2-min treatment performed. v. vein.

possibly standard of care for the management of saphenous vein insufciency. This less invasive technique has been shown to have a high technical success rate, low morbidity if performed properly, and high patient satisfaction, and is very successfully performed in an ofce setting.

6. 7.

References
1. Pannier F, Rabe E: Endovenous laser therapy and radiofrequency ablation of saphenous varicose veins. J Card Surg 47:3-8, 2006 2. Stirling M, Shortell CK: Endovascular treatment of varicose veins. Semin Vasc Surg 19:109-115, 2006 3. Almeida JL, Raines JK: Radiofrequency ablation and laser ablation in the treatment of varicose veins. Ann Vasc Surg 20:547-552, 2006 4. Hirsch SA, Dillavou E: Options in the management of varicose veins. J Card Surg 49:19-26, 2008 5. Kundu S, Laurie F, Millward SF: Recommended reporting standards for endovenous ablation of the treatment of venous insufciency: Joint

8. 9. 10.

11.

statement of the American Venous Forum and the Society of Interventional Radiology. J Vasc Inter Rad 18:1073-1080, 2007 Bush RL, Constanza RM: Endovenous saphenous and perforator vein ablation. Sem Vasc Surg 21:50-53, 2008 Roland L, Dietzek AM: Radiofrequency ablation of the great saphenous vein performed in the ofce: tips for better patient convenience and comfort and how to perform it in less than an hour. Pers Vasc Surg Endovasc Ther 19:309-314, 2007 Peden EK, Lumsden AB: RF ablation of incompetent perforators. Endo Today 1:15-17, 2007 (suppl) Dietzek AM: Endovenous radiofrequency ablation for the treatment of varicose veins. Vasc 15:255-261, 2007 Luebke T, Gawenda M, Heckenkamp J, et al: Meta-analysis of endovenous radiofrequency obliteration of the great saphenous vein in primary varicosis. J Endovasc Ther 15:213-223, 2008 Proebstle TM, Vago B, Alm J, et al: Treatment of the incompetent great saphenous vein by endovenous radiofrequency powered segmental thermal ablation: rst clinical experience. J Vasc Surg 47:151-156, 2008

Subfascial Endoscopic Perforator Surgery (SEPS)

Mark D. Iafrati, MD, RVT, FACS

he term chronic venous insufciency (CVI) is used to describe the clinical sequelae of prolonged (years) venous hypertension, which include lower extremity swelling, pain, pigmentary changes, and ulceration. The time-tested clinical pillars of elevation, compression, exercise, and skin care are fundamental to the management of CVI, but to be effective these interventions require a high degree of patient compliance. For many patients, especially those living in warmer climates or with active lifestyles, compliance with elevation and compression therapy is poor. The recently published Effect of Surgery and Compression on Healing and Recurrence (ESCHAR) trial randomized 500 patients with active or healed venous ulcers (C5-C6) to compressive therapy alone or compressive therapy plus venous surgery.1 After 14 months, there was a dramatic decrease in ulcer recurrence rates in the patients who underwent surgery in addition to compression as compared with those receiving compression therapy only (15% vs. 34%; P 0.001). In other words, even when appropriate conservative therapy is adhered to, the underlying venous pathology remains and patients benet from surgical treatment. Although a comprehensive approach to the supercial, deep, and perforating venous systems is appropriate, this article will concentrate on subfascial endoscopic perforator surgery (SEPS).

pass from the subcutaneous space to the deep posterior compartment, by traversing the supercial posterior compartment (Fig 3A) or entering the deep posterior compartment directly (Fig 3B) requiring paratibial fasciotomy for exposure (Fig 3C).

Indications for SEPS

Directed treatment of ICPVs with SEPS or endovenous ablation is generally reserved for patients with advanced CVI (C4-6); current data do not support the application of these techniques in patients with uncomplicated varicose veins (C2-3). The patients overall medical status should obviously be considered, as surgery is preferred in young, t patients with low surgical risk and an extended period of benet. The choice of anesthesia is individualized with reference to the patients general medical condition and planned surgery. SEPS has been commonly employed as an adjunctive procedure during GSV ligation and stripping for patients with class 4 to 6 CVI who have combined supercial and perforator reux, allowing both procedures to be accomplished under a single anesthetic. However the recent trend toward ofce-based endovenous saphenous vein ablation under local anesthesia has resulted in an uncoupling of these procedures in many cases. When staged, elimination of GSV reux should be performed rst because this will generally result in the greatest hemodynamic benet and in some cases eliminate perforator reux altogether. Catheter based techniques, both RF and laser, have also been applied directly to the treatment of ICPVs. Although appealing to our general thirst for all things less invasive, endovenous perforator ablation is technically more challenging than saphenous vein ablation, often requiring cannulation of multiple irregular PVs through diseased skin, with limited ultrasound visualization, and application of heat in close proximity to the posterior tibial veins. Though this technique may ultimately prove benecial, data are currently lacking and we reserve this technique for PVs that would be difcult to access with SEPS, such as inframaleolar of lateral calf PVs.

Anatomy
Perforating veins (PVs) connect the supercial to the deep venous system, perforating the fascia. In the normal limb, the PVs permit the unidirectional ow of blood from the supercial to the deep venous system through a set of oneway valves. When these valves fail, reux, in varying patterns, exists (Fig 1). There are six groups of PVs in the leg: those of the foot, ankle, leg, knee, thigh, and gluteal regions. Incompetent perforating veins (ICPVs) are most clinically signicant (and most commonly observed) about 5 to 10 cm above the medial malleolus. Cadaver studies have identied 7 to 20 medial calf PVs, which connect the posterior accessory great saphenous vein or other tributaries with the posterior tibial vein. The many traditional eponyms associated with the PVs have been recently replaced with an anatomically based nomenclature (Fig 2).2,3 All medial calf PVs

Technique
Under general or regional anesthesia the patient is positioned with their leg elevated at the knee and ankle; leaving the calf unsupported improves exposure. The primary incision is made in the upper calf in normal-appearing skin, and a second 5 mm instrument port is placed 5 cm posterior and distal

Division of Vascular Surgery, Tufts Medical Center, Boston, MA. Address reprint requests to Mark D. Iafrati, MD, RVT, FACS, Chief, Division of Vascular Surgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111. E-mail: miafrati@tuftsmedicalcenter.org

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Figure 1 PVs connect the supercial to the deep venous system. In the normal limb (A), the PVs permit the unidirectional ow of blood from the supercial to the deep venous system through a set of one-way valves. PVs are either direct, permitting the supercial venous system to communicate directly with the main deep veins, or indirect, such that they connect with the deep veins by way of a muscular vein. Although supercial and deep venous disease may result from either obstructive or reux pathology, perforator disease is exclusively a manifestation of reux disease. Reux may occasionally be isolated to PVs but is more commonly associated with supercial reux (B), deep system reux alone (not shown), or deep and supercial reux (C).

Figure 2 There are six groups of PVs in the leg, those of the foot, ankle, leg, knee, thigh, and gluteal regions. ICPVs are most clinically signicant and most commonly observed about 5 to 10 cm above the medial malleolus. Cadaver studies have identied 7 to 20 medial calf PVs. These perforators connect the posterior accessory great saphenous vein or other tributaries of the saphenous vein directly with the posterior tibial vein. The many traditional eponyms (A) associated with the PVs have been recently replaced with a newer anatomical nomenclature (B).2,3 Ext. external; v. vein; Post. posterior; PV perforating vein.

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Figure 2 (Continued)

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Figure 3 All medial calf PVs pass from the subcutaneous space to the deep posterior compartment, by one of two routes: Approximately two-thirds traverse the supercial posterior compartment (A) whereas the remaining third enter the deep posterior compartment directly (B). This is signicant, as the initial exposure in subfascial endoscopic perforator ligation reveals only the supercial posterior compartment (open spaces in A and B); identication of all PVs therefore requires paratibial fasciotomy (C). v. vein; PAV posterior arch vein (old)/posterior accessory saphenous vein (new).

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Figure 4 Under general or regional anesthesia the patient is positioned with their leg elevated at the knee and ankle. Leaving the calf unsupported improves exposure. The leg may be exsanguinated with an esmarch bandage and a pneumatic tourniquet inated on the thigh above arterial pressure. This maneuver protects against CO2 embolization and minimizes bleeding in the eld that can signicantly limit visualization. Incisions are made in the upper calf, in normal appearing skin. The initial incision (A) should be at least 10 cm distal to the tibial tuberosity and 5 cm lateral to the edge of the tibia to avoid impacting the bones with the scope. Placing the incision more distally will facilitate exposure in the lower calf/ankle, but the lipodermatosclerotic skin is to be avoided. If a two port technique is utilized the second port (B) (5 mm instrument port) will be placed 5 cm posterior and distal to the rst. The incision(s) is extended through the subcutaneous fat and the lamina supercialis of the deep fascia is visualized. The fascia is transversely opened approximately 12 mm and blunt subfascial dissection is performed with a snap or ngertip.

to the rst (Fig 4). Only the supercial fascia is opened to expose and insufate the supercial posterior compartment. The procedure is performed with either a working scope containing a through lumen to pass instruments or with a second 5 mm trocar inserted under endoscopic visualization (Fig 5). The initial subfascial surgical dissection plane is within the supercial posterior compartment. In this space, approximately 70% of the lower medial leg PVs (Cockett 2) and 15% of mid medial leg PVs (Cockett 3) veins are not initially visible to the operator (Fig 3).2 As illustrated these hidden

perforators traverse directly from the deep posterior compartment to the subcutaneous tissue without entering the supercial posterior compartment. This is an extremely important anatomic fact, because the majority of the ICPVs occur at the mid to lower medial calf level. To access the remaining perforators, the lamina profunda fascia of the deep posterior compartment must be incised through a paratibial fasciotomy (Fig 3C). The dissection plane in the medial mid calf is generally quite adequate. However, the distal extent of the subfascial dissection becomes rather conned (Fig 5). This tight work-

Figure 5 Use of a balloon expansion device (US Surgical, Norwalk, CT) allows the subfascial plane (supercial posterior compartment) to be easily extended toward the ankle. A screw adapter or balloon xation port is inserted into the anterior incision and CO2 insuation at 15 to 25 mm Hg expands the space, greatly improving visualization. The procedure is performed with either a working scope containing a through lumen to pass instruments or with a second 5 mm trocar inserted under endoscopic visualization. At this point the instruments are in the supercial posterior compartment and dissection along the anterior/medial aspect of the eld will identify PVs that are seen running vertically across the eld. PVs are divided with a harmonic scalpel or clipped with a 5 mm endo clip, the vein is divided, and the dissection is then carried distally.

142 ing space can make treatment of the lowest leg and ankle PVs challenging. In this location, use of a single port operating scope is particularly benecial because it eliminates the problem of dueling instruments competing for limited space. In addition endovenous ablation techniques are particularly well suited to this location. In the thigh there are fewer PVs, but they can be clinically important. The medial thigh and femoral canal PVs run between and communicate with the femoral or popliteal vein and the great saphenous vein either directly or indirectly. The thigh perforators are often disrupted in the process of treating the supercial venous system, but when they do require direct intervention they are readily accessible via direct surgical exposure and not appropriate for SEPS.

M.D. Iafrati
sion wraps, paste boots, etc), topical therapies for skin and ulcer care, and surgical correction of venous insufciency both obstructive and reux disease. A thoughtful approach to the treatment of venous reux requires a variety of approaches to the correction of venous disease in different locations of the leg and in different venous systems. Over the last two decades, SEPS has been proven to be a safe and effective means of eliminating ICPVs of the medial calf. This technique allows excellent visualization of the supercial posterior compartment and the paratibial portion of the deep posterior compartment and allows multiple PVs to be identied and divided. The technique is limited, however, in its ability to reach very distal perforators near the ankle; percutaneous endovenous perforator ablation has shown promise in this area but data are lacking. SEPS therefore remains a valuable technique for the modern venous surgeon.

Results
The high rates of concomitant supercial venous surgery and SEPS in most reported series makes a precise determination of the impact of SEPS impossible at the current time. However, a systematic review of the SEPS literature through 2004 (1,220 limbs) demonstrated SEPS to be safe ( 1% DVT) and effective (90% ulcer healing and 10% recurrence).4 Performance of SEPS alone creates a measurable improvement in venous hemodynamics,5 although durability is not perfect (21% incidence of recurrent PVs at a mean of 3.7 years after SEPS).6 In the only large randomized trial of this procedure, SEPS was found to be associated with signicantly improved ulcer-free survival, the benet being most apparent in the most difcult ulcers (duration 4 months, size 250 mm2).7

References
1. Barwell JR, Davies CE, Deacon J, et al: Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): Randomised controlled trial. Lancet 363:1854-1859, 2004 2. Mozes G, Gloviczki P, Menawat SS, Fisher, Carmichael SW, Kadar A: Surgical anatomy for endoscopic subfascial division of perforating veins. J Vasc Surg 24:800-808, 1996 3. Caggiati A, Bergan JJ, Gloviczki P, et al: Nomenclature of the veins of the lower limb: Extensions, renements, and clinical application. An International Interdisciplinary Consensus Committee on Venous Anatomical Terminology. J Vasc Surg 41:719-724, 2005 4. TenBrook JA, Iafrati MD, ODonnell TF, et al: Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J Vasc Surg 39:583-589, 2004 5. Proebstle TM, Weisel G, Paepcke U, et al: Light reection rheography and clinical course of patients with advanced venous disease before and after endoscopic subfascial division of perforating veins. Dermatol Surg 24:771-776, 1998 6. Roka F, Binder M, Bohler-Sommeregger K: Mid-term recurrence rate of incompetent perforating veins after combined supercial vein surgery and subfascial endoscopic perforating vein surgery. J Vasc Surg 44:359363, 2006 7. van Gent WB, Hop WC, et al: Conservative versus surgical treatment of venous leg ulcers: A prospective, randomized, multicenter trial. J Vasc Surg 44:563-571, 2006

Conclusion
Modern management of patients with chronic venous insufciency should involve a multifaceted approach including medical management of comorbidities (diabetes, renal insufciency, heart failure, nutritional deciencies, etc), compression therapy (compression garments, multilayer compres-

Catheter Directed Thrombolysis for Iliofemoral Deep Vein Thrombosis

Devang Butani, MD, and David L. Waldman, MD, PhD

he annual incidence of clinically recognized acute deep venous thrombosis (DVT) in the United States is estimated to be between 116,000 and 250,000.1 This risk increases with age, immobility, hypercoagulable states, oral contraceptives, the postsurgical and postpartum periods, and after trauma. The most feared complication, pulmonary embolus (PE), occurs in about 10% of cases. The most common and costly complication, however, is chronic venous insufciency (true postphlebitic syndrome). Greater than 90% of symptomatic PE originates from the leg veins.2 Conventional treatment is simple anticoagulation, the goals of which are to prevent propagation of clot, relieve local symptoms, and prevent PE. Anticoagulation does not, however, physically remove the thrombus, only prevent propagation and embolization. Physical clot removal is associated with improved long-term outcome. Surgical removal is associated with very high recurrence rates, and is rarely performed. With the advent of catheter-based therapy, however, results are much better, and in cases where the benet is expected to exceed the risk, aggressive endoluminal removal of thrombus should be considered.

tervention to decrease compartment pressures and resolve ischemia. Thrombolysis accomplishes these goals very well. Factors limiting widespread use of percutaneous therapy are lack of prospective, randomized data, safety concerns of thrombolytic agents versus anticoagulation, cost of inpatient catheter directed therapy versus outpatient anticoagulation, lack of awareness by primary care physicians that these techniques exist, and lack of an accepted reporting system and clinical benet endpoint.3 Because postphlebitic syndrome is such a late complication randomized clinical trials are difcult to perform, although the long-term nancial impact and quality if life in patients with established postphlebitic syndrome are poor.

Patient Selection
As described above, certain patients can be anticipated to have unusual benet from active thrombolysis. These include those with signicant iliofemoral clot burden and acute phlegmasia (symptom onset less than 10 days), young patients, and patients with May May-Thurner syndrome. Eligibility for thrombolytic therapy and subsequent anticoagulation requires, in general, absence of active bleeding, absence of stroke within the past 12 months, no recent intracranial or intraspinal surgery, and absence of pregnancy or coagulopathy. Patients need to be otherwise reasonably healthy and have a near-normal life expectancy (as the major benet lies in the future). Patients with DVT related to diffuse malignancy or malignant obstruction are not ideal candidates. Patients who are already anticoagulated usually undergo emergent correction before thrombolysis. IVC lters are placed only if potentially embolic thrombus (free oating) is identied in the iliac vein or IVC, or if the patient has an unequivocal new major thrombus despite adequate anticoagulation.

Treatment Options
Once DVT is conrmed by imaging (usually sonographic evaluation) a typical, clinically stable, patient is medically treated with anticoagulation. Catheter-directed thrombolysis should be considered, however, for young patients at risk for postphlebitic chronic venous problems, patients with possible May-Thurner syndrome (a reversible cause), patients with severe local symptoms, and patients with overwhelming symptomatic outow obstruction and limb threat (phlegmasia) (Fig 1). Postphlebitic syndrome is debilitating and occurs very late, often not becoming symptomatic for up to 10 to 15 years after the original DVT; aggressive therapy to remove clot is the best way to preserve valvular function, which will reduce the chances and severity of postphlebitic syndrome. Phlegmasia, by denition, requires aggressive and urgent in-

Procedure
Prior imaging studies are reviewed to evaluate the extent of the DVT. Before thrombolysis, CBC with platelets, BUN, creatinine, and eGFR are obtained, the patients history and physical examination are reviewed, and informed consent is obtained. A very critical point is that thrombolysis is catheter-directed; that is, delivered within the clot itself, not adminis143

Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY. Address reprint requests to Devang Butani, MD, Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: Devang_Butani@urmc.rochester.edu

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Figure 1 It is probably still fair to say that conventional anticoagulation remains the default treatment for most patients with deep vein thrombosis (DVT), although it is not accurate to call this the gold standard. Aggressive physical removal of clot burden has the advantage of yielding better long-term outcome, although adds the drawbacks of the risk of vessel access and thrombolytic administration along with signicant nancial and logistical burdens. Conservative therapy consists of acute heparinization, either via intravenous unfractionated heparin infusion or subcutaneous administration of low-molecular weight heparin. The latter can be administered as an outpatient with equivalent safety and efcacy; hospitalization is rarely required today. Either way, warfarin is administered to a goal INR of approximately 2. Current recommendations are to treat for 6 months for a rst episode, lifetime if a second has occurred. As described above, certain patients can be anticipated to have unusual benet from active clot removal. These include young patients (lower short-term risk and a greater lifespan to accrue long-term benet), patients with potential May-Thurner syndrome (a correctable cause of DVT), and those with enough clot burden to cause unusually severe symptoms (either very severe local pain or true phlegmasia). Eligibility for thrombolytic therapy and subsequent anticoagulation requires, in general, absence of active bleeding, absence of stroke within the past 12 months, no recent intracranial or intraspinal surgery, and absence of pregnancy or coagulopathy; patients need to be otherwise reasonably healthy and have a near-normal life expectancy (as the major benet lies in the future) and patients with DVT related to diffuse malignancy or malignant obstruction are not ideal candidates.

tered systemically. The patient is placed prone on the table (another critical point as it results in a reversed image; physicians involved in these cases must be aware of this) and the popliteal vein is accessed using ultrasound (Fig 2). A small amount of contrast is injected to evaluate thrombosis and secure sheath access obtained. An angled hydrophilic catheter and hydrophilic wire are used to navigate the thrombus and gain access to the inferior IVC. The inferior IVC is

examined to evaluate the superior extent of the thrombus. Once the inferior and superior extent of the thrombus is determined, a suitable infusion catheter is selected based on the length of the thrombus, with the goal being to bathe the entire thrombus with thrombolytic drug. At our institution, Alteplase (rt-PA; Genentech, San Francisco, CA) is most commonly used at a rate of 0.5 mg/hr, with concurrent systemic heparin at 800 U/hr (Fig 3).

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Figure 2 DVT is diagnosed/conrmed using duplex ultrasound (B-mode imaging of the area along with Doppler ow detection). Acute thrombosis is not usually echogenic; the B-mode image itself is often normal. The vessels are located and compression applied. A patient without DVT will have a very easily compressible vein, whereas the adjacent artery will not compress without unusual pressure. A patient with acute thrombosis, however, will show lack of compression of the vein, even if the thrombus cannot be directly visualized. A very critical point is that thrombolysis must be catheter-directed; that is, delivered within the clot itself, not administered systemically. The patient is placed prone on the table (another critical point as it results in a reversed image; physicians involved in these cases must be aware of this) and the popliteal vein is accessed using ultrasound. A small amount of contrast is injected to evaluate thrombosis and secure sheath access obtained. Access is at times problematic as liquid blood is usually not aspirated; entrance into the vein depends on good ultrasonic visualization along with experience and feel. An angled hydrophilic catheter and hydrophilic wire are used to navigate the thrombus and gain access to the inferior IVC. The wire should pass easily and follow the expected track of the vein. Note the situation at the iliac conuence; the RIGHT iliac artery passes over (anterior to) the LEFT iliac vein, often producing extrinsic compression and secondary LEFT sided iliofemoral DVT (May-Thurner syndrome). IVC lters are placed only if potentially embolic (free oating) thrombus is identied in the iliac vein or IVC, or if the patient has an unequivocal new major thrombus despite adequate anticoagulation. v. vein.

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Figure 3 Again, note that the patient is placed prone on the procedure table. After proper access, sheath placement, and wire passage into the inferior vena cava (IVC), the IVC is examined radiographically to evaluate the superior extent of the thrombus. Once the inferior and superior extent of the thrombus is determined, a suitable infusion catheter is selected based on the length of the thrombus, with the goal being to bathe the entire thrombus with thrombolytic drug. At our institution, Alteplase (rt-PA; Genentech, San Francisco, CA) is most commonly used at a rate of 0.5 mg/hr, with concurrent systemic heparin at 800 U/hr. After thrombus debunking the catheter and sheath are secured and patient monitored overnight. It is important that the patient be placed on a oor with appropriately trained staff, to ensure regular monitoring for abnormal bleeding and maintenance of the catheter and sheath, although ICU care is not typically needed as this is a venous problem with low-pressure vessels being involved. The patient is brought back for evaluation in 24 h and the interval change guides further treatment. If complete resolution of thrombus is seen and no underlying stenosis found, no further intervention is needed. If complete resolution of thrombus is seen but underlying iliac vein disease is present (almost always extrinsic compression of the left iliac vein by the overlying right iliac artery; May-Thurner syndrome), angioplasty followed by stent placement yields excellent results. If the thrombus has resolved but underlying femoral vein disease is present, angioplasty is performed but stenting avoided. Finally, if only partial resolution is seen, infusion therapy continues. This can be supplemented with further mechanical intervention and/or repositioning of the catheter if needed. These patients are re-evaluted by venography at appropriate intervals for a maximum of three infusion periods and/or 48 h total treatment.

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Figure 4 Mechanical thrombolysis refers to the technique of physical, usually real-time removal of thrombus (as opposed to allowing lytic drugs to break up clot). These techniques can be used before beginning chemical thrombolysis or during treatment, as choice of technique, experience, and individual ndings suggest. The two most common techniques are the Angiojet (Possis Medical, Minneapolis, MN) and the Arrow-Trerotola PTD (Arrow International, Reading, PA). The Arrow-Terotola PTD device acts as an eggbeater to physically macerate clot in the area shown; the macerated clot, ideally of very small particulate size, will pass centrally and be taken care of by the lungs. By contrast, the Angiojet physically removes clot by means of the Venturi effect produced by a jet of high-velocity crystalloid solution. Treatment area for the Angiojet is obviously less than the Terotola device, but this technique carries with it the advantage of physically removing the thrombus rather than sending it proximally within the body. Although experience is less with this device, the Trellis device (Bacchus, Santa Clara, CA) potentially combines the benets of both. This device consists of two balloons with a rotating sine-wave-shaped catheter and infusion/aspiration ports between them. After the balloons are inated, treatment is instituted in 10-min increments, with infusion of 5 mg or so of t-PA and adjustment of the nodes of rotation during this interval. After this, the macerated, t-PA infused debris are aspirated and the catheter repositioned and the process repeated. This device has the theoretical benet of very rapid treatment of the entire lesion in one sitting; if residual thrombus is present t-PA can then be infused per protocol above for a short period of time, but usually thrombus removal is complete.

148 Mechanical thrombolyisis can also be used, usually before beginning chemical thrombolysis. The two most common techniques are the Angiojet (Possis Medical, Minneapolis, MN) and the Arrow-Trerotola PTD (Arrow International, Reading, PA). These devices are used to decrease clot burden before beginning pharmaceutical lysis. Additional techniques include the combination of Angiojet and pulse spray infusion of rTPA4 and use of the rotating Trellis device (Bacchus, Santa Clara, CA) with aspiration of macerated, t-PA infused debris after treatment (Fig 4). After thrombus debunking the catheter and sheath are secured and patient monitored overnight. It is important that the patient be placed on a oor with appropriately trained staff, to ensure regular monitoring for abnormal bleeding and maintenance of the catheter and sheath, although ICU care is not typically needed as this is a venous problem with lowpressure vessels being involved. The patient is brought back for evaluation in 24 h and the interval change guides further treatment. If complete resolution of thrombus is seen and no underlying stenosis found, no further intervention is needed. If complete resolution of thrombus is seen but underlying iliac vein disease is present (almost always extrinsic compression of the left iliac vein by the overlying right iliac artery; MayThurner syndrome), angioplasty followed by stent placement yields excellent results (Fig 3). If the thrombus has resolved but underlying femoral vein disease is present, angioplasty is performed but stenting avoided. Finally, if only partial resolution is seen, infusion therapy continues. This can be supplemented with further mechanical intervention and/ or repositioning of the catheter if needed. These patients are re-evaluted by venography at appropriate intervals for a maximum of three infusion periods and/or 48 h total treatment. All patients are anticoagulated for at least 6 months after thrombolysis, typically on heparin as a bridge to oral warfa-

D. Butani and D.L. Waldman

rin, with a goal INR 2 to 3. Patients with iliac stents are placed on 6 weeks of clopidogrel as well. Imaging follow-up includes baseline Doppler ultrasound followed by re-imaging at 6 and 12 months. For iliac stenting, the Stanford study has shown a 1 year patency rate 90%.5

Conclusions
Anticoagulation alone (heparin followed by oral warfarin) is rmly ingrained as the treatment for DVT in medical education and practice. Catheter-directed thrombolysis has the major advantage of actively and quickly removing clot (as well as identifying an underlying lesion causing the problem) but requires logistically complex, expensive, and somewhat risky treatment regimens, and is thus currently reserved for patients who present with limb threat (phlegmasia), locally symptomatic disease, or those who are young and healthy. Various infusion regimens and novel protocols, some involving combinations of mechanical thrombectomy and infusion thrombolysis, are in use. Well-designed, prospective, randomized data, along with appropriate treatment regimens are needed to modify the treatment of DVT.

References
1. Anderson FA, Wheeler HB, Goldberg RJ, et al: A population based perspective of the hospital incidence and case fatality rates of deep vein thrombosis and pulmonary embolism. Arch Intern Med 151:933-938, 1991 2. Plate G, Ohlin P, Eklof B: Pulmonary embolism in acute ileofemoral venous thrombosis. Br J Surg 72:912-915, 1985 3. Semba CP, Razavi MK, Kee ST, et al: Thrombolysis for lower extremity deep venous thrombosis. Tech Vasc & Int Rad 7:68-78, 2004 4. Mohsen Shari, MD, Mahshid Mehdipour, David Skloven, et al: Case study and review: Power-pulse spray and angiojet thrombectomy in massive inferior vena cava and bilateral lower extremity deep venous thrombosis. Vascular Disease Management 5:62-65, 2008 5. OSullivan GO, Semba CP, Bittner CA, et al: Endovascular management of iliac vein compression (May-Thurner) syndrome. J Vasc Intervent Radiol 11:823-836, 2000

Internal Jugular Vein Turndown for Subclavian Vein Occlusion

Son Ha Yu, MD, and Ralph B. Dilley, MD, FACS

s described in the previous two articles, effort thrombosis (Paget-Schroetters disease) refers to primary thrombosis of the subclavian vein as result of exertion of the upper extremity. The underlying cause is compression of the subclavian vein at the costoclavicular space and is exacerbated with repetitive arm and shoulder activity. This dynamic compression leads to brosis of the vein, progressive obstruction, and subsequent thrombosis. It is most commonly seen in athletes, painters, beauticians, and many others who are highly functional.1,2 Secondary subclavian vein thrombosis, actually more common than primary, can also occur because of the presence of a central venous catheter in the subclavian vein. Thrombosis may occur in as many as one third of patients with subclavian catheters, although only 10% to 50% are symptomatic.3 Primary effort thrombosis, as described in previous articles, is treated today by thrombolysis (mechanical or pharmacologic) followed by scalenectomy and rst rib resection through a supraclavicular, infraclavicular, or transaxillary approach. A signicant number of patients with subclavian vein thrombosis, however, will develop a brous stenosis or occlusion resulting in venous hypertension and its associated symptoms. If severe injury to the vein has occurred (most commonly chronic total occlusion) and symptoms are severe, one approach to decompression is through performance of a jugular venous turndown.

patient with an occluded subclavian-axillary venous system that is unable to be relieved by catheter-based techniques AND is highly symptomatic. Obviously, the IJ vein and superior vena cava must be patent.

Preoperative Evaluation
Although duplex ultrasonography may suggest the presence of a proximal obstruction, its accuracy is limited because of the presence of the clavicle. An ascending/antegrade upper extremity phlebogram is required for diagnosis and to identify the location and extent of obstruction, required for operative planning. Assessment of BOTH internal jugular veins is mandatory; a patent ipsilateral vein is required for the procedure, but as this vein will no longer contribute to cerebral drainage, patency of the contralateral jugular as well is required.

Operative Technique
The procedure is performed with the head turned to the opposite the side of the intended incision and the chest, neck, and shoulder widely draped. A longitudinal incision is made along the anterior border of the sternocleidomastoid (SCM) muscle. To facilitate necessary exposure of the entire length of the IJ vein, the incision is extended from the clavicular head to the retromandibular area curving slightly and extending outward behind the earlobe to reduce the risk of injury to the marginal mandibular nerve (Fig 1). Circumferential dissection along the length of the IJ vein identies the common facial vein and possible ancillary branches. The cephalad-most portion is dissected to the level of the mastoid process, and the caudal end is extensively mobilized into the thoracic outlet via division of the omohyoid muscle, again ligating and dividing any branches of the vein. A separate 8-10 cm incision is made 2 cm below the clavicle (Fig 2); alternatively, the medial two-thirds of the clavicle can be resected for complete decompression and direct exposure. The incision is then deepened through the deltoid-pectoral groove thus exposing the clavipectoral fascia. The clavipectoral fascia is identied and divided to expose adipose tissue and the axillary sheath; care must be taken to preserve any and all accessory venous collateral vessels to avoid further compromising the upper 149

Indications
The ideal treatment of primary axillo-subclavian vein thrombosis is thrombolysis followed by decompression of the thoracic outlet. In many cases, however, the occlusion is organized and obstruction cannot be relieved. In this setting the ipsilateral internal jugular (IJ) vein can be transposed to the subclavo-axillary vein distal to the obstruction thus allowing inow to the heart bypassing the obstruction. Currently, the indication for IJ turndown is a

Division of Vascular Surgery, Scripps Clinic Medical Group and Scripps Green Hospital, La Jolla, CA. Address reprint requests to Ralph B. Dilley, MD, FACS, Senior Consultant, Scripps Clinic Medical Group, and Surgeon-in-Chief, Scripps Green Hospital, 10666 North Torrey Pines Road, La Jolla, CA 92037. E-mail: dilley.ralph@scrippshealth.org

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Figure 1 General anesthesia is induced, and the patient placed supine on the operative table with the head turned opposite the side of the intended incision. A roll beneath the shoulders, either transverse (to extend the neck) or between the shoulder blades to also allow the shoulders to fall backwards is helpful. The surgical eld should include the neck at least to the earlobe, chest, and shoulder. A longitudinal incision is made along the anterior border of the sternocleidomastoid (SCM) muscle, and extended from the clavicular head to the retromandibular area curving slightly posteriorally to reduce the risk of injury to the marginal mandibular nerve. A second incision is placed below the clavicle. Alternatively, the medial two-thirds of the clavicle can be resected in which case the subclavian/axillary vein can be easily found after resection of the subclavius muscle (often facilitated by tracking the cephalic vein down). m. muscle.

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Figure 2 The IJ vein is located and dissected free. Circumferential dissection along the length of the IJ vein is performed to well above the common facial vein; this along with ancillary branches is divided. The cephalad-most portion is dissected to the level of the mastoid process, and the caudal end is extensively mobilized into the thoracic outlet via division of the omohyoid muscle, again ligating and dividing any branches of the vein. Providing as much length as possible will ensure the vein will reach without undue tension or kinking. The infraclavicular incision (or claviculectomy) is made at this time to expose the subclavian/axillary complex. Again, if the medial clavicle is resected (not shown), exposure is straightforward once the subclavius muscle is resected. The clavipectoral fascia is identied and divided to expose adipose tissue and the axillary sheath; care must be taken to preserve any and all accessory venous collateral vessels and associated nerves. To facilitate full exposure of the rst and second parts of the axillary vein medially, the pectoralis minor muscle may be fully or partially divided, the lateral pectoral nerves being identied and spared. m. muscle; v. vein; a. artery.

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Figure 3 A subclavicular tunnel is bluntly created. This must be large enough to accommodate the passage of the IJ vein, and should travel underneath the SCM muscle. If the clavicle has been resected, this tunnel involves soft tissue only. It should be emphasized that this tunnel needs to be large and wide open, and the proximal portion of the IJ vein needs to be fully dissected, mobilized, and loose; this is not a tunnel made by a metal tunneler, but one made bluntly with clear visualization and plenty of room. After heparinization, the IJ vein is divided at its cephalad-most point near the mastoid process, tunneled with unusual care taken to avoid kinking or twisting, and an end-to-side venovenous anastomosis performed. Before completion, the anastomosis is ushed antegrade and retrograde to remove any air or loose debris. The clamp is then removed and hemostasis achieved. Suction drains are left in place brought out through separate stab incisions. v. vein.

extremity should the IJ vein anastomosis occlude.4 To facilitate full exposure of the rst and second parts of the axillary vein, the pectoralis minor muscle may be fully or partially divided and retracted laterally, the lateral pectoral nerves being identied and spared.5 A subclavicular tunnel is bluntly created. This must be large enough to accommodate the passage of the IJ vein, and should travel underneath the SCM muscle (Fig 3). After heparinization, the IJ vein is divided at its cephalad-most point, tunneled, and an end-to-side venovenous anastomosis performed. Creation of a temporary arteriovenous stula to increase blood ow through the newly constructed venous anastomosis is often recommended, although denitive data regarding efcacy does not exist. In our practice we add a radiocephalic stula at the time of the jugular turndown which is ligated 3-6 months after operation. Obviously, if the procedure is being performed because of venous hypertension in a patient with a dialysis stula in place, this step has already been taken care of.

Postoperative Care
Continuous heparin administration while warfarin therapy reaches therapeutic levels is instituted routinely based on general principles, although again data are lacking. Anticoagulation is usually continued 3 to 6 months; follow-up includes duplex ultrasound and probably phlebography before the discontinuation of warfarin therapy. If the patient has a documented (or strongly suspected) hypercoagulable state, anticoagulation should be continued indenitely. Frequent follow-up ofce visits should be scheduled at the discretion of the surgeon; whether follow-up should be lifelong or as directed by symptom recurrence is unknown.

Conclusions
Internal jugular turndown for symptomatic axillary-subclavian vein thrombosis provides excellent anatomic drainage with a large-diameter autologous conduit and only one anastomosis, and is well-tolerated in this fre-

IJ vein turndown for subclavian vein occlusion

quently young, often healthy population. Unfortunately, large series are lacking, but anecdotal experience and several case reports and small series show long-term symptomatic relief in the large majority (80-90%) of patients. This is an important tool to have in dealing with patients suffering from this condition.

153
2. Green RM: Subclavian vein thrombosis, in Rutherford RB (ed). Vascular Surgery (ed7). New York, NY, Elsevier Saunders, 2005, pp 1371-1374 3. Puskas JD, Gertler JP: Internal jugular to axillary vein bypass for subclavian vein thrombosis in the setting of brachial arteriovenous stula. J Vasc Surg 19:939-942, 1994 4. Gertler JP: Decompression of the occluded subclavian vein in the patient with ipsilateral threatened access by transposition of the internal jugular vein. ASAIO J 41:896-898, 1995 5. Valentine RJ, Wind GG: Anatomic exposures in vascular surgery (ed 2). Philadelphia, Lippincott Williams & Wilkins, 2003, p 163

References
1. Kommareddy A, Zaroukain MH, Hossounia HI: Upper extremity deep venous thrombosis. Semin Thromb Hemost 28:89-99, 2002

The Inferior Vena Cava and Iliac Veins: Management of Operative Injuries, Obstruction, and the Palma Procedure
Patrick R. Cook, DO, FACS, and Ralph B. Dilley, MD, FACS

here is extensive information regarding management of traumatic ileocaval injury in both military1 and civilian2 experience, but there is relatively little data available concerning the management of iatrogenic operative venous injuries. Risk factors for iatrogenic inferior vena cava (IVC) injury include retroperitoneal surgery for cancer, operation in the setting of unusual anatomy or difcult exposure, and patients who have undergone previous surgery, have a recurrent tumor, or who have had radiation therapy.1 Laparoscopy continues to expand and an increasing number of complex procedures are being performed; this trend (and perhaps Natural Oriface Transluminal Endoscopic Surgery) will also add to the incidence of iatrogenic ileocaval injury. The rst step is obviously to recognize that an injury to a major vein has occurred. Management at this point is largely dependant on the hemodynamic stability of the patient in conjunction with the severity and location of the injury. In the hemodynamically unstable patient, ligation of the vessel may be the best option as it achieves prompt hemostasis, minimizes operative time and allows for correction of acidosis, blood loss, and hypothermia.2 Most patients with operative IVC injuries, however, have partial lacerations that can be managed with relatively simple techniques such as lateral venorrhaphy, end-to-end anastamosis, or patch angioplasty with prosthetic or autologous vein. As with all vessel repairs it is important to achieve a tension-free repair, and because these veins have low pressure within, minimization of stenosis is unusually important.

Techniques of IVC Repair

The patient will likely be under general anesthesia at the time of consultation. These patients often are or will become quite ill, so if not already performed (and priorities permit), nasogastric and urinary drainage, appropriate monitoring, warmth, and antibiotics should all be addressed. If not al-

Division of Vascular Surgery, Scripps Clinic Medical Group and Scripps Green Hospital, La Jolla, CA. Address reprint requests to Ralph B. Dilley, MD, FACS, Senior Consultant, Scripps Clinic Medical Group, and Surgeon-in-Chief, Scripps Green Hospital, 10666 North Torrey Pines Road, La Jolla, CA 92037. E-mail: dilley.ralph@scrippshealth.org

ready undergoing operation, the patient should be positioned supine with access to the anterior chest, thighs, and at least one leg for vein harvest if necessary. Resuscitation efforts obviously should take priority if needed. A very important principle is that of immediate control. If the injury is major, it is critical not to waste time and blood by extensive dissection. Proximal and distal control as an immediate solution does not work well in major central venous injuries because of the depth of the vessels, high ow with low pressure, incoming branches, and lack of valves. Instead, the area of bleeding should be massively packed or direct pressure held, with the objective being to stop the ongoing blood loss (by admittedly temporary means) as fast as possible. This will allow two things to happen: the anesthesia team can catch up, and the surgical and anesthesia team can think through the problem and mobilize resources. In other words, for a major injury, resist the temptation to start with denitive measures; stop the bleeding temporarily with pressure, take a deep breath, make a plan, and communicate with the rest of the team. Assuming the patient is undergoing laparotomy, the intestines are eviscerated and the abdomen is packed. Once relative hemodynamic stability is obtained attention can then be turned to exposure of the injured IVC. This is best accomplished by a right medial visceral rotation with a Kocher maneuver if the location of the injury is believed to be relatively high (Fig 1). The IVC can be approached anteriorly if the injury site is clearly seen in the retroperitoneum at the time of initial exploration, especially if low. Hemostasis can then be obtained with digital pressure or the placement of sponge sticks both proximally and distally to the site of injury and the application of compression against the vertebral bodies (Fig 2). Clamps or vessel loops should be avoided until the injury is clearly identied as they may result in further injury. For clearer delineation of the injury site, the loose retroperitoneal fatty tissue must be dissected away. Once cleanly dissected a Satinsky vascular clamp may be applied to partially allow ow if the injury permits. Anterior perforations of the IVC can generally be managed by means of a transverse repair using monolament suture. Concomitant posterior injury must always be considered, but the level of suspicion depends on the mechanism of injury. If

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Figure 1 The patient will likely be under general anesthesia at the time of consultation, and often the vascular (or trauma) surgeon will arrive to a blood-lled eld. If so, the abdomen is packed with specic attention paid to the right retroperitoneum. Once relative hemodynamic stability is obtained attention can then be turned to exposure of the injured IVC. This is best accomplished by a right medial visceral rotation with a Kocher maneuver, especially if the exact location o f the injury is known or suspected. The IVC can be approached anteriorly if the injury site is clearly seen in the retroperitoneum at the time of initial exploration. Injuries at the iliac conuence can frequently be difcult to expose; excellent visualization can be obtained by dividing the overlying right iliac artery (which will subsequently need to be repaired). v. vein.

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Figure 2 An important principle is to stop the bleeding early by temporary means if needed. In addition to allowing the anesthesia team to resuscitate the patient, this allows the surgical team to stop, think, and gather resources. Is a different surgeon needed? Does the surgeon, even if competent to treat the injury, need more help? What approach should be used? Hemostasis can then be obtained with digital pressure or the placement of sponge sticks both proximally and distally to the site of injury and the application of compression against the vertebral bodies; clamps or vessel loops should be avoided until the injury is clearly identied as they may result in further injury and because of the many branches fail to control bleeding at all. Only when bleeding has been controlled by direct pressure should better exposure be sought. IVC inferior vena cava; v. vein.

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Figure 3 Once bleeding has been temporarily controlled, plans made, and resources gathered, clean exposure should be sought. Anterior perforations of the IVC can generally be managed by means of a transverse repair using 5-0 polypropylene suture. A Satinsky-type vascular clamp may be applied to allow venorrhaphy while maintaining caval ow, but exposure and repair should not be compromised and total occlusion of the cava to achieve expeditious permanent repair is frequently required. The aorta can be cross clamped temporarily if hypotension is severe. Posterior injury is more common after penetrating trauma, but can also occur iatrogenically (eg, during nephrectomy for tumor). Depending on location, the anterior surface of the cava can be incised and the posterior defect repaired from the inside. Thorough vascular control will need to be obtained using vessel loops, clamps, and manual compression. If there is contamination of the wound secondary to a bowel injury consideration should be given to the placement of an omental patch in an effort to prevent later breakdown of the suture line(s). Consideration should be give to placing all knots on the outside of the lumen, but no evidence exists supporting or refuting this practice. IVC inferior vena cava.

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Figure 4 On occasion the injury pattern does not allow a simple venorrhaphy. In patients with a complex laceration or transection, reconstructive options vary. If there is little actual tissue loss, end-to-end anastomosis using 5-0 polypropylene can be performed provided the anastomosis can be performed without tension. Complete control of the IVC is essentially always required because of the magnitude of these injuries. Again, aortic cross clamping can be simultaneously performed if the combination of blood loss and lack of venous return produce signicant hypotension, especially if repair will take more than a few minutes. In the circumstance where there is segmental loss and a tension free repair or anastomosis cannot be carried out, an interposition graft or application of a patch using prosthetic or autologous vein will be required. IVC inferior vena cava.

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Figure 5 After induction of general anesthesia both groins and thighs are prepped in draped in a sterile fashion. Attention is rst turned to the unaffected limb where a longitudinal incision is made over the common femoral vein. The saphenofemoral junction is meticulously dissected and all branches temporarily preserved. The outow or unaffected limbs saphenous vein is then dissected free ensuring appropriate length. This can be performed via a single longitudinal incision, several interrupted incisions, or using endoscopic vein harvest techniques. a. artery; v. vein.

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Figure 6 In a similar fashion in the contralateral groin a longitudinal incision is made and the common femoral vein, saphenofemoral junction, and deep femoral vein are exposed and encircled with vessel loops. Enough distal dissection should be performed to ensure a patent segment is present. A subcutaneous suprapubic tunnel is then created between the two groin wounds. Moistened umbilical tape is passed to estimate the length of vein needed for the bypass. GSV great saphenous vein.

Inferior vena cava and iliac veins

161

Figure 7 The patient should be heparinized at this point. The vein is transected distally and ushed with heparinized saline to ensure adequate dilation and absence of kinking or leakage. Because the vein will not be pressurized to the same degree as it is during arterial bypass, consideration should be given to marking orientation at this point even if it is not the surgeons usual practice. The vein is then passed through the subcutaneous tunnel using conventional techniques. An anteromedial longitudinal venotomy in a patent segment of common femoral vein or greater saphenous vein in the obstructed limb is then created. The length of the venotomy should be 1.5 to 3 times the diameter of the venous conduit, and unusual care should be taken to orient the venotomy to ensure that the low-pressure saphenous vein lies comfortably after anastomosis. Intraluminal webs are frequently found in recanalized vessels and should be excised if present. An end-to-side anastomosis is then fashioned, using running 6-0 monolament suture. Consideration should be given to using an interrupted technique (commercial clips or interrupted sutures) to provide better theoretical compliance behavior, but evidence for this does not exist.

162 present, the anterior injury can be extended and the posterior defect repaired intraluminally (Fig 3) unless the injury is in a very mobile, easily rotated portion of vein. Injuries to the iliac conuence or proximal left common iliac vein can be quite difcult to visualize for repair. In these cases, the right common iliac artery can be divided, making exposure almost trivial (and then reanastomosed after control of hermorrhage). On occasion the injury pattern does not allow a simple venorrhaphy and end-to-end anastomosis (or interposition grafting) must be performed. Complete control of the IVC will obviously need to be obtained. This markedly reduces venous return to the right heart and aortic cross clamping should be simultaneously performed if hypotension is significant (Fig 4). If there is segmental loss and a tension-free repair cannot be performed, an interposition graft or patch will be required if hemodynamic stability permits. Prosthetic grafts offer the advantages of size match and expeditious availability, but are associated with a greater risk of infection and decreased long-term patency. The use of autologous vein, however, is time consuming and carries with it size and length mismatch problems. Most clinicians and authors advocate the use of autologous vein only in contaminated wounds.1,3 Finally, if there is contamination of the wound secondary to a bowel injury consideration should be given to the placement of an omental patch between the bowel and the venous repair in an effort to prevent anastomotic breakdown.

P.R. Cook and R.B. Dilley

Technique of Crossover Saphenous Vein Bypass

After induction of general anesthesia both legs are prepped in draped in a sterile fashion. The saphenofemoral junction of the unaffected limb is dissected free (Fig 5), and the saphenous vein dissected distally and transected ensuring appropriate length. The vein conduit is then ushed with heparinized saline to ensure adequate dilation without kinking or leakage. The groin of the affected/obstructed limb is then dissected free, and a suprapubic subcutaneous tunnel fashioned (Fig 6). The procedure proceeds with the creation of an anteromedial longitudinal venotomy in the patent segment of common femoral vein or greater saphenous vein in the obstructed limb, 1.5 to 3 times the diameter of the venous conduit.7 Intraluminal webs are frequently found in patients with chronic obstruction and should be excised. An end-toside anastomosis is created (Fig 7). A small catheter can then placed through a branch of the affected greater saphenous vein to perform on-table phlebography. There is debate regarding the advisability of creating an AV stula at the time of the bypass to increase ow, usually temporarily. Proponents feel it is helpful because the venous system possesses thin fragile vessels with generally low intraluminal pressure and slow velocities, and the addition of this extra ow may improve patency.8 However, others argue that the disadvantage of requiring a second operation (classically at 3 months) to ligate the stula outweighs any theoretical benet, and point out that no denitive data exist. In our practice we always perform an AV stula in the affected groin which we take down in 3-6 months.

Crossover Saphenous Vein Bypass (Palma Procedure)

If bleeding is massive and/or the patient unstable, virtually any vein in the body can be ligated. If ileocaval repair is impossible because of patient instability, the abdomen can be packed and operation terminated to allow resuscitation. At times, the iliac veins must be ligated for similar reasons. Although patients may do well, others can develop limbthreatening acute venous gangrene because of lack of outow. In this situation the cross-femoral venous bypass (Palma procedure), originally used for chronic venous disease, can be considered. Palma and colleagues reported the rst such crossover bypass procedure,4 and Dale subsequently contributed to its popularization.5 At one time crossover saphenous vein bypass was the most frequently performed reconstructive procedure for chronic obstructive iliac venous disease. This procedure is infrequently performed today because of the improvement in nonoperative care of venous disease and the success of endovascular interventions such as thrombolysis and stenting. There are, however, still circumstances in which endovascular intervention is unsuccessful or impossible (eg, chronic organized thrombus, venous aplasia, intraluminal webs, or severe extrinsic compression,6 or acute occlusion [injury itself or ligation to control hemorrhage] where collaterals have not had a chance to develop). The Palma procedure can be used to re-establish venous outow from the affected limb provided the contralateral iliofemoral system, the vena cava, and the saphenous vein are patent.

Results
The operation is seldom performed today, and no large contemporary series exist. Historical results, however, have been surprisingly good. Halliday and associates reported 89% 5-year clinical patency and 75% 7-year venographic patency rates,9 whereas Dale and colleagues reported a 75% long term clinical patency rate. Results were described as excellent 63% of patients and good in 17% (20% failed).10

Conclusions
Iatrogenic ileocaval injuries represent potentially lethal complications. Immediate identication and early repair of the injury with concomitant aggressive resuscitation will minimize morbidity and mortality in this patient population, although with major injuries in an unstable patient temporary control by means of direct pressure or packing to allow resuscitation, planning, and mobilization of resources should be the rst step. Most injuries can be managed by means of venorrhaphy, end-to-end anastomosis, or patch angioplasty. In the more complex injury patterns interposition grafting may be required. For the patient with signicant hemodynamic instability ligation may be the best option. If iliac ligation is required, consideration should be given to cross femoral bypass (as patient stability permits). The Palma procedure is an excellent option for chronic iliac occlusion as

Inferior vena cava and iliac veins

well, with historically excellent patency and clinical success rates.

163
5. Dale WA, Harris J: Cross-over vein grafts for iliac and femoral venous occlusions. Ann Surg 168:319, 1968 6. Comerota AJ, Aldridge SC, Cohen G, et al: A strategy of aggressive regional therapy for acute iliofemoral venous thrombosis with contemporary venous thrombectomy or catheter-directed thrombolysis. J Vasc Surg 20:244-254, 1994 7. Smith DE: Surgical management of chronic obstructive venous disease of the lower extremity, in Rutherford RB (ed). Vascular Surgery. Philadelphia: WB Saunders, 1984, p 1412 8. Reber PU, Patel AG, Genyk I, et al: Crossover saphenous vein bypass (Palma) in phlegmasia cerulean dolens caused by total iliac outow obstruction. J Am Coll Surg 189:527-529, 1999 9. Halliday P, Harris J, May J: Femoro-femoral crossover grafts (Palma operation): A long term follow-up study, in Bergan JJ, Yao JST (eds). Surgery of the Veins. New York: Grune & Stratton, 1985, pp 241-254 10. Dale WA: Crossover vein grafts for iliac and femoral venous occlusion. Res Staff Phys March 1983, p 58

References
1. Oderich GS, Panneton JM, Hofer J, et al: Iatrogenic operative injuries of abdominal and pelvic veins: A potentially lethal complication. J Vasc Surg 39:931-936, 2004 2. Shama PV, Ivatury RR, Simon RJ, et al: Central and regional hemodynamics determine optimal management of major venous injuries. J Vasc Surg 16:887-894, 1992 3. Zamir G, Berlatzky Y, Rivkind A, et al: Results of reconstruction in major pelvic and extremity venous injuries. J Vasc Surg 28:901-908, 1998 4. Palma EC, Esperon R: Vein transplants and grafts in the surgical treatment of the post-phlebitic syndrome. J Cardiovasc Surg 1:94, 1960