A 21-year-old male, with no known previous medical illness, presented with a 9-days history of the non-dominant left arm swelling. Duplex ultrasonography examination revealed thrombosis of the left basilic vein from the upper arm level extending proximally to the left axillary and subclavian veins.
Catheter-directed thrombolysis was performed with recombinant tissue plasminogen activator (rtPA) in a dose of 1 mg/h. Recanalization of left basilic, axillary and subclavian veins was achieved after 48 h of thrombolysis with short residual stenosis located in the proximal subclavian vein. Balloon angioplasty was not performed prior the first rib resection.
Significant swelling reduction of the arm was achieved after the thrombolysis. The patient was anticoagulated with continuous infusion of unfractionated heparin during the thrombolysis. The anticoagulation was switched to low-molecular-weight heparin (LMWH) afterwards. Thoracic outlet decompression surgery from transaxillary approach was performed the next day. Despite continued anticoagulation with therapeutic dose of LMWH after the 1st rib resection, routine angiography control 1 day after the surgery revealed early rethrombosis of left basilic, axillary and subclavian veins (Fig. 1A, B). Fluoroscopy confirmed adequate extend of 1st rib resection.
The right basilic vein was accessed, and percutaneous mechanical thrombectomy was performed. Aspirex 6F and 8F thrombectomy devices (Straub Medical, Wangs, Switzerland) were used to fragment the thrombus and to aspirate it from the vessel. Completion angiography showed restoration of venous patency and near complete thrombus removal, with only minor residual thrombosis of the subclavian vein, without significant stenosis (Fig. 1C, D). Haematological examinations did not reveal any hypercoagulable state. The patient was kept on LMWH for 1 month, followed by dabigatran for another 2 months. Long-term antiplatelet therapy with acetylsalicylic acid (ASA) was recommended afterwards.
During follow-up, patient’s arm had returned to normal, and he has remained asymptomatic. Duplex ultrasound controls 6 and 12 months after the procedure confirmed patent venous system.