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Introduction

Even after successful thrombolysis and thoracic outlet decompression, many patients will still require some form of venous reconstruction. Authors’ and clinicians’ attitudes vary widely as to the number of patients who will need this (literally from zero to every patient) and it should be stressed that no randomized comparisons exist.

Indications

Reconstruction may be performed early, immediately following thrombectomy, or in a delayed fashion. If after thrombolytic therapy there is significant residual stenosis or if lytic therapy has failed, some surgeons perform open ­thrombectomy and endovenectomy at the time of first rib resection to decompress the subclavian vein. Thus, the external (ligaments, muscles, and first rib that surround the vein) and internal (fibrosis and organized thrombus) factors causing subclavian vein thrombosis are treated simultaneously [1].

Other surgeons defer surgery following successful or even unsuccessful lytic therapy and follow the patient on anticoagulants. Surgery may be performed a few weeks later while some physicians will only perform surgery for persistent symptoms.

For chronic subclavian vein occlusion, or when occlusion persists in spite of treatment and when symptoms present significant disability, subclavian vein reconstruction is available. However, reconstruction should not be considered until several months have passed after occlusion occurred. The reason for this is collateral circulation can develop during the first 6–12 months following occlusion. In the majority of patients symptoms subside to the point where they are no longer disabling and the residual symptoms are mild enough that surgery is not needed.

If reconstruction is indicated three approaches are available: jugular vein turndown, endovenectomy, or replacement with vein graft or prosthesis.

Incision

All subclavian vein reconstructions are performed through one of two incisions: Claviculectomy or infraclavicular. There are advantages and disadvantages to each. Claviculectomy provides the best exposure but at the risk of some complications from removing one of the supports of the shoulder girdle (see Chap. 64). In a minority of patients instability of the shoulder girdle may cause some impairment particularly for young active people who do heavy lifting with their arms [2], although the majority of patients who have received claviculectomy are happy with the end result and experience no disability [3].

Infraclavicular incisions preserve the clavicle but the exposure is not as good and the procedure is more difficult, especially in large patients.

Claviculectomy

Claviculectomy is covered in more detail in Chap. 64, but a few points are worth emphasizing. Excision of the clavicle provides the best exposure for all patients, but especially in the obese. As much as possible of the clavicle should be removed(at least two-thirds to three-quarters); removing a shorter length carries a risk of the medial end of remaining clavicle dropping onto the neurovascular bundle causing symptoms of venous obstruction or brachial plexus compression, and from a disability point of view there is no difference between excision of a short or long segment of clavicle. The periosteum should be removed to avoid regeneration of what could become weak bone, and the clavicular head is disarticulated at the sternum [3, 4].

Infraclavicular Incision

The infraclavicular incision is used far more often than claviculectomy. An 8–10 cm transverse incision is made just lateral to the sternum and 2 cm below the clavicle. Pectoralis major is split in the direction of its fibers, and the subclavian and axillary veins are dissected free. Depending on the type of reconstruction to be done, the pectoralis minor muscle may be divided for better exposure of the axillary vein. The anterior two-thirds of the first rib should be excised prior to performing endovenectomy or replacement graft but the first rib need not be removed for a jugular vein turndown. First rib resection includes release of the anterior scalene and middle scalene muscles. The posterior part of the first rib is difficult to excise through this incision but when possible, enough rib is removed to leave the lower trunk of the brachial plexus free of the posterior rib stump.

Sternal Split

When the thickened portion of subclavian vein extends proximally beneath the sternum, the proximal subclavian vein is exposed by carefully freeing the vein from the back of the sternum by blunt dissection. When enough soft vein cannot be freed to apply a proximal vascular clamp, better exposure can be obtained by splitting the sternum to the first interspace as described by Molina (this is also an alternative to claviculectomy for access to the infraclavicular subclavian vein) [5]. The medial corner of the skin incision is retracted medially to expose the sternal notch. It may be necessary to extend the skin incision medially to see the notch. The periosteum of the sternum is incised and by finger dissection the underside of the sternum is freed down to the first interspace. More blunt dissection is added under the first rib interspace until the two dissections meet. A ­sternal knife or saw splits the sternum ­vertically down to the first interspace and horizontally through the first interspace until the two cuts meet. After controlling hemorrhage from the bone edges with bone wax, the freed piece of sternum is retracted upwards, held by a self-retaining retractor, and the entire venous system including innominate, subclavian, axillary, and jugular veins are nicely exposed (Fig. 65.1) [5].

Fig. 65.1
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Sternal flap for exposure of subclavian, innominate, and jugular veins (Reprinted from Molina [5] with permission from Elsevier)

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Once the vein repair is complete and hemostasis achieved, the sternum is repaired with 3 or 4 heavy braided Dacron or wire sutures inserted through predrilled holes. Although the original description of the sternal closure used only two wire sutures, we have found adding an additional one or two sutures makes the closure more secure. Postoperatively, the patient is instructed to restrict use of the arm for 6–8 weeks but also to gently raise the arm each day to 180° to avoid a frozen shoulder.

Subclavian Endovenectomy and Interposition Graft

These techniques are used in situations where “significant” (variously and subjectively defined) intraluminal stenosis or complete occlusion are present, and require exposure as above. Again, definitive proof is lacking; some advocate ­reconstruction in virtually all patients and some only in those who are highly symptomatic.

Preoperative Evaluation

A venogram is essential to confirm adequate inflow from the brachial vein as well as to define the extent of axillosubclavian vein stenosis or occlusion. The procedure can’t be performed if inflow is inadequate, and accurate assessment of a normal central vessel for outflow is critically important.

Technique

Following claviculectomy or infraclavicular exposure and first rib resection, the subclavian vein is dissected circumferentially as far distally as necessary to find soft axillary vein. Branches are preserved and controlled with vessel loops. By lifting the vein on a right angle clamp to identify absence of intraluminal material the distal and proximal points of the venotomy can be determined. To find soft vein proximally it is often necessary to carefully dissect the vein beneath the sternum, and if soft vein cannot be reached centrally, the sternum is split as described above.

Endovenectomy

The patient is heparinized and the section of vein to be opened is isolated between vascular clamps. Venotomy is performed and a patent channel sought. Organized thrombus and scarred intima are excised (Fig. 65.2). It should be stressed that there are no dissection planes between intima and adventitia as in arterial endarterectomy; endovenectomy is a totally different operation. The scarred material inside the vein wall is excised with a sharp scissors taking care to avoid getting too close to the adventitia and perforating the vein wall, and a rim of firmly attached rough-surfaced intima or organized clot, 1–2 mm thick, is left inside the vein wall. A patch of saphenous vein or homograft vessel is used to close the venotomy.

Fig. 65.2
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Endovenectomy. (a) Location of incision in vein. (b) Scissors excision of scarred intima. (c) Vein patch graft (Reprinted from Sanders and Haug [7], p. 252 with permission from Lippincott Williams & Wilkins)

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Replacement Graft

If the vein is too badly scarred or fibrosed so that a reasonable channel cannot be identified and developed, the obliterated segment is excised and replaced with a 10–14 mm graft, such as ­cryopreserved aortic homograft or a saphenous vein panel graft; prosthetic is not recommended in this situation. The graft is sewn proximally and distally with monofilament permanent suture (Prolene or similar).

If the wound is dry the heparin need not be neutralized. The patient is started on warfarin immediately and after 24 h is started on intravenous heparin or subcutaneous low molecular weight heparin. Low molecular weight Dextran is started during surgery and continued for 24–48 h postoperatively. Once the warfarin has reached therapeutic levels (INR  =  2–3) the heparin is stopped. Anticoagulation with ­warfarin is continued for 3–6 months postoperatively.

Jugular Turndown (Jugular Vein Transposition)

If the length of occlusion is 5–6 cm long or less, a jugular vein turndown is possible [6]. Longer occlusions cannot be managed with a jugular turndown because the jugular vein won’t stretch any further. This procedure requires a normal jugular vein on the ipsilateral side and an open jugular vein on the contralateral side.

Preoperative Evaluation

As for endovenectomy, a preoperative venogram is necessary to confirm adequate inflow and to determine the length of the total occlusion (again, an occlusion over 6 cm long will usually not be a candidate for a jugular turndown). Ultrasound is used to determine patency of the ipsilateral and contralateral jugular veins.

Incision

Either an infraclavicular incision or claviculectomy as described above is used to begin the operation. A moist sponge is placed in the wound while the jugular v. is prepared.

The internal jugular v. is dissected free through two 5 cm transverse incisions in the neck, one 2 cm above the clavicle and the other 3–4 cm below the mandible (Fig. 65.3a). Beginning in the lower incision, the internal jugular v is found by splitting muscle fibers of sternocleidomastoid to expose the vein. The vein is dissected circumferentially and surrounded with a quarter inch Penrose drain. From this point the vein is mobilized completely down to the clavicle and up as high as possible. Proximal dissection is then continued through the upper incision continuing to free the vein, first distally to meet the dissection from the lower incision and then cephalad to the base of the skull. The facial vein is ligated and divided.

Fig. 65.3
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Jugular vein turndown. (a) Location of incisions. (b) Jugular vein being passed through tunnel under clavicle. (c) Completed jugular-subclavian vein ­anastomosis. (d) Completed turndown (Reprinted with permission from Sanders and Haug [14] with permission from Elsevier)

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Before dividing the vein, a tunnel is created by blunt dissection from the axillary vein, under the clavicle, and into the supraclavicular space. The tunnel is enlarged by dividing the subclavius muscle. In the supraclavicular space the tunnel is extended to the internal jugular vein just above the clavicle.

The proximal jugular v. is marked with a suture on its upper surface to avoid twisting when pulled through the tunnel. Proximally, the vein is suture ligated close to the base of the skull and the ­jugular vein transected. The vein is pulled distally through the open vein bed and completely freed as distally as possible below the clavicle while paying attention to keep the marking suture upright. A valve in the vein prevents back bleeding so it is usually unnecessary to clamp the vein. Using a kidney pedicle clamp the jugular vein is pulled through the tunnel, again observing vein orientation to prevent twisting (Fig. 65.3b). One way to check for twisting is to pass a size 20–24 Fr. catheter up the jugular v. and into the SVC which should pass with ease; if not, the vein should be reoriented until the catheter does pass easily.

The axillary vein is occluded with vascular clamps or vessel loops and the jugular vein sewn end-to-side or end-to-end into it (Fig. 65.3c). Flow through the jugular vein is evaluated and the graft followed through its supraclavicular path releasing any kinks (Fig. 65.3d). The wounds are closed with subcutaneous and subcuticular absorbable sutures [7, 8].

Arteriovenous Fistula (AVF)

Because venous reconstructions are low pressure systems, they may thrombose more readily than arterial reconstructions. It has been demonstrated that this can be prevented by increasing flow and pressure across the suture line with a temporary arteriovenous fistula (AVF) [9–13]. This can be done with a Teflon reinforced PTFE prosthesis between the axillary artery and axillary vein distal (peripheral) to the axillary suture line which is looped to lie in the subcutaneous tissue making taking down the fistula fairly easy by dividing the prosthesis in the subcutaneous tissue and tying each end [12, 13]. Alternatively, an AVF can be created in the arm or forearm. The fistula is closed in 6–12 weeks.

We advocate constructing a temporary AVF after any of the venous reconstructions described above. While good results are obtainable without an AVF, data suggest that the added security of temporarily increasing flow across the fresh suture lines makes adding the AVF a worthwhile procedure [9–11].