Four patients with primary subclavian-axillary vein thrombosis are described. Each patient received local thrombolytic therapy, resulting in reestablishment of antegrade flow via the axillary and subclavian veins. An intrinsic venous abnormality (perimural fibrosis and/or intimal dissection) identified at the first rib-clavicle junction (subclavian-axillary vein junction) was thought to be responsible for the thrombosis. One of the four patients subsequently underwent a surgical venous bypass of the abnormal segment, and a second underwent percutaneous transluminal angioplasty.

Fifty-seven local transcatheter infusions of low doses of fibrinolytic agents for the treatment of occlusive vascular disease were performed in 49 patients. Thrombosis developed around the infusing catheter in 15 (26%) of these cases. Patients with occlusive vascular disease are at increased risk for the development of thrombosis around indwelling catheters because of the low flow state that exists proximal to the occlusion.

The authors report their experience with the first 57 infusions (50 patients) in an ongoing study of local low-dose fibrinolysis for treatment of thromboembolic disease. Complete lysis occurred in nearly half of cases, while some therapeutic effect was demonstrable in more than two thirds. Success seems to be most directly related to the type of vessel infused, with the greatest success seen in vessels with no alternate pathways for egress of the fibrinolytic agent. Chronic fibrin deposits could also be treated with this technique. Since new thrombus formation occurs in a significant percentage of patients during local fibrinolytic therapy, the authors recommend cautious use of concomitant continuous intravenous heparin at a dosage sufficient to maintain the partial thromboplastin time at 1.5 times normal. While fibrinolytic therapy is usually not curative, it frequently facilitates detection of the underlying lesion, permitting definitive therapy.

Five patients underwent preoperative embolization of osseous metastases from renal cell carcinoma. The group consisted of four men and one woman who ranged in age from 46 to 79 years. The lesions were located in the pubic ramus and acetabulum, proximal femur, femoral midshaft, proximal humerus, and proximal tibia. All embolizations were performed within 24 hours of surgery. The internal fixation and tumor curettage was accomplished with estimated perioperative blood loss ranging from 10 ml to 1,250 ml. All patients had significant restoration of function following surgery. We suggest that preoperative embolization is an important and efficacious adjunct in the management of hypervascular renal cell osseous metastases.

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