For years, patients with "effort"
thrombosis were treated by
anticoagulants and conservative exercise; and if recurrent symptoms developed when they returned to work, they were considered for first-rib resection. Recently, use of
thrombolytic agents with early
surgical decompression of the neurovascular compression has markedly reduced morbidity, such as
postphlebitic syndrome and the necessity for
thrombectomy. A review of 67 patients seen over 25 years showed that 34 were initially treated with
heparin sodium and then
Coumadin (crystalline
warfarin sodium). Recurrent symptoms developed in 21 after they returned to work and necessitated transaxillary first-rib resection to relieve symptoms. Eight also underwent
thrombectomy. Recently, 33 patients were initially treated with
thrombolytic agents and
heparin, followed promptly by early first-rib resection. The evaluation and efficacy of this
therapy have been established by frequent and repetitive venograms and careful follow-up of patients. Most of the patients showed improvement with
thrombolytic agents. Remaining
stenoses that suggested intravascular
thrombosis were usually secondary to external compression of the vein by the clavicle, costoclavicular ligament, rib, or scalenus anterior muscle. Venous
thrombectomy was necessary in only 4 patients in whom the clot was not controlled by
thrombolytic therapy and operative release of compression. There were no deaths in the series.