Postoperative Duplex Ultrasound Surveillance After First Rib Resection for Venous Thoracic Outlet Syndrome: A Single-Center Experience

Introduction: Methodology of postoperative surveillance in patients undergoing first rib resection (FRR) for venous thoracic outlet syndrome (vTOS) remains controversial. The role of duplex ultrasound (DUS), a noninvasive method of surveillance, after surgical decompression for vTOS requires assessment. Methods: A retrospective review analyzed adult patients undergoing FRR for vTOS between 2019 and 2024 at a tertiary center. Upper-extremity (UE) venous DUS with provocative maneuvers was performed at 1, 3, 6 months, and annually, using a standardized protocol in an accredited vascular laboratory. Ultrasounds assessed patency, flow, thrombus, collaterals, coupled with clinical findings. Acute thrombosis after FRR indicated recurrence. Kaplan-Meier analysis evaluated follow-up and recurrence rates. Results: Forty-seven patients underwent 49 FRR procedures. Mean age was 32 years (range, 18-54 years). Thirty-six patients had a history of UE deep vein thrombosis, and 24 underwent preoperative intervention. A total of 158 postoperative DUS examinations were performed. Visualization limitations were reported in 9 studies (6.7%) and collaterals were identified in 46 studies (29.1%). Duplex ultrasound detected chronic thrombus or scarring in 21 cases and acute thrombosis in 6 patients, prompting postoperative ancillary procedures in 26 instances. Median follow-up was 145 days, with rapid attrition during the first 6 months. Estimated freedom from recurrence was approximately 90% at 1 year. There were no perioperative deaths. Discussion: Structured imaging can complement decompression by detecting residual or recurrent venous pathology amenable to treatment. Our results show that, post-FRR, DUS may be more suited to longitudinal surveillance of visualization limits, collateralization, respiratory phasicity, and provocative changes. The technical limitations of postoperative DUS are manageable. Visualization obstruction and the presence of collaterals were generally limited and manageable, indicating that despite anatomical complexity, DUS yielded actionable information in most examinations. Conclusion: Duplex ultrasound is an informative surveillance tool after FRR for vTOS. It identified postoperative abnormalities, guiding reintervention. Despite occasional limitations, DUS is a practical modality for postoperative monitoring after vTOS decompression.