Subclavian venous occlusion due to thoracic outlet syndrome

A middle-aged male truck driver presented with a 4-week history of left upper extremity swelling and tenderness. Pulses were normal, and there were no sensory or motor abnormalities. Initial imaging studies (chest radiography, venous duplex) were negative. The left basilic vein was cannulated for venography, which showed occlusion of the left subclavian and innominate veins (A). Thrombolysis using tPA at 1 mg/hour over 36 hours successfully recanalized the thoracic central veins. An attempt to angioplasty a mid-subclavian vein stenosis (B) using a compliant 8 mm balloon was unsuccessful due to compression of the subclavian vein between clavicle and first rib (C). Four hours after thrombolysis and attempted angioplasty, infraclavicular resection of 1st rib and lysis of perivenous scar tissue were performed. Postoperative venography showed a widely patent left subclavian vein (D). The patient was discharged to home fully anticoagulated, which was discontinued after 3 months, thereafter aspirin therapy was initiated to be continued indefinitely.