Central venous stenosis (CVS) is one of the most challenging complications in hemodialysis patients. Venous thoracic outlet syndrome (vTOS) is an underappreciated cause of CVS in a dialysis patient which may result in failed percutaneous intervention and loss of a functioning dialysis access. Limited data exist about the safety and outcome of first rib resection in HD patients, and results have been confounded by variable surgical approaches. The purpose of this study was to evaluate the safety, operative outcomes, and patency of the existing dialysis access after trans-axillary thoracic outlet decompression.
A retrospective chart review was performed from January 2008 to December 2019 of patients who underwent thoracic outlet decompression for subclavian vein stenosis with ipsilateral upper extremity hemodialysis access. Baseline characteristics and comorbidities were reviewed. Operative and post-operative course were evaluated. Survival and patency rates were analyzed using life-table method and Kaplan-Meier curve.
A total of 18 extremities in 18 patients were identified. Mean age was 59 ± 11 years and 89% were male. There were 13 fistulas and 5 grafts included. All patients underwent repair via a trans-axillary approach. First rib resection, anterior scalenectomy and circumferential venolysis were performed in all patients. Mean operative time was 99 ± 19 minutes with an estimated blood loss of 78 ± 66 mL. Median length of stay was 2 days. There was no death at 30 days. Survival rate at 1-year was 83%. Primary, primary assisted, and secondary patency at 1- year were 42%, 69%, and 93%, respectively.
Thoracic outlet decompression via trans-axillary approach is a technically feasible and safe operation in the patient with ipsilateral upper extremity hemodialysis access. Patients with threatened dialysis access due to subclavian vein stenosis should be carefully evaluated for possible extrinsic compression at the costoclavicular junction. These patients may benefit from trans-axillary first rib resection, scalenectomy and venolysis.

Copyright © 2021. Published by Elsevier Inc.