Primary Effort Thrombosis: Treatment Options in Acute and Chronic Disease—Case Reports

Primary axillary-subclavian vein thrombosis (effort thrombosis) is a unique variant of thoracic outlet syndrome that effects young, active adults. The majority of cases have been demonstrated to be secondary to contriction of the axillary- subclavian vein junction between the interval of the clavicle and the first thoracic rib. Owing to the limited clinical experience with this disorder, prevention of long-term disability has resulted in several proposed surgical procedures that have not always decreased late morbidity. Recently the availability of fibrinolytic agents has improved therapeutic results in primary thrombotic syndromes. The authors report 4 cases involving both acute and chronic effort thrombosis treated either by (1) sequential therapy involving fibrinolytic agents, anticoagulation, then decompressive surgery (first rib resection), (2) anticoagulation and first rib resection or (3) fibrinolytic agents and long term anticoagulation without surgery. Their experience with both acute and chronic effort thrombosis has resulted in sustained venous patency without the need for chronic anticoagulation in those patients who ultimately underwent rib resection as part of their treatment. The authors believe that this sequential therapy is the treatment of choice in the management of both phases of this syndrome and will eliminate the need for long-term anticoagulation and drastically reduce long-term disability.