Timing Of Operative Therapy

Thrombolysis results in recanalization of the vein and relief of arm swelling, aching, heaviness, and other symptoms. Until a few years ago, the maxim was that following lytic therapy, the patient should be anticoagulated for four to six weeks with warfarin, and after this time had passed, a transaxillary first rib resection would be performed. This algorithm was based more on a theoretical consideration of the perivenous inflammation rather than any data suggesting that early rib resection was hazardous. This algorithm was challenged by a number of groups performing early first rib resection with equal safety, and the added benefit of avoiding prolonged warfarin use in these young patients. We reported on the safety of such an approach wherein following thrombolysis, we performed a transaxillary first rib resection on the same admission with no difference in complications or efficacy.16

Accordingly, we would now recommend that the patient presenting with acute axillo-subclavian vein thrombosis should have a venogram, lytic therapy, followed by transax-illary first rib resection on the same admission. This approach results in quick and definitive therapy. Recognizing that in a subset of patients (approximately 30%) there will be a residual venous stricture despite decompression of the thoracic outlet due to long-standing extrinsic compression, it is our practice to perform a venogram on all patients approximately two weeks following first rib resection. If a significant stenosis is identified at that time, a percutaneous transluminal angioplasty (PTA) is performed. These lesions respond very nicely to PTA alone and we have not found the use of a stent in this situation necessary. Figure 52.3 demonstrates the venogram of one such patient that had thrombolysis, transaxillary first rib resection, followed by PTA of a venous stenosis two weeks following first rib resection.

How To Deal With Rosacea and Eczema

How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

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