Dedicated venous stent placement across the thoracic outlet: will novel venous stents transform axillosubclavian vein thrombosis treatment paradigm?

Abstract

Background: Endovascular stenting is widely accepted as the standard treatment for central venous obstruction syndromes such as superior vena cava (SVC) syndrome due to its demonstrated clinical efficacy and improved patient outcomes. However, its application in axillosubclavian vein thrombosis (ASVT) has been limited due to concerns about stent compression within the thoracic outlet. This report aims to evaluate the feasibility and safety of the off-label use of dedicated venous stents-engineered with enhanced mechanical features-as an alternative endovascular approach for the treatment of ASVT.

Methods: Thirty-eight patients (43 affected limbs) with symptomatic ASVT and no prior treatment or surgical decompression underwent endovascular placement of dedicated venous stents across the thoracic outlet with Abre Venous Stents (Medtronic, Dublin, Ireland), Venovo Venous Stents (BD, Franklin Lakes, NJ, USA), or Vici Venous Stents (Boston Scientific, Marlborough, MA, USA). Stents were extended peripherally to the subclavian or axillary veins and centrally to the brachiocephalic vein or SVC. Technical success was defined as successful stent deployment across the costoclavicular space, and clinical success as symptomatic improvement.

Results: Stent placement was technically successful in all 43 limbs (100%), with clinical improvement observed in 97.4% of patients. The one patient without clinical improvement experienced early thrombosis of the stent, requiring mechanical thrombectomy and additional stenting. Follow-up CT venography at a mean of 301.3 days demonstrated high primary stent patency rates (81.4%), with stent crushing observed in only 7.0% of limbs and no instances of stent fracture. Adverse events were limited, including two access site hematomas and one hypotensive episode, all of which resolved without evidence of long-term complications.

Conclusions: Our findings suggest that stenting across the thoracic outlet for the treatment of ASVT may be a viable option with the use of novel dedicated venous stents, potentially expanding treatment strategies for TCVO.