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Outcomes of Surgical Paraclavicular Thoracic Outlet Decompression
Outcomes of Surgical Paraclavicular Thoracic Outlet Decompression Sapan S. Desai, Mohammad Toliyat, Anahita Dua, Kristofer M. Charlton-Ouw, Monir Hossain, Anthony L. Estrera, Hazim J. Safi, and Ali Azizzadeh, Houston, Texas
Background: Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery, resulting in neurogenic (NTOS), venous (VTOS), and arterial (ATOS) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of paraclavicular surgical decompression for TOS. Methods: A prospective analysis of patients who underwent surgical decompression for TOS at a newly established center was performed. Diagnosis of TOS was based on clinical history, a physical examination, and additional diagnostic studies. The indication for surgery in patients diagnosed with NTOS was the presence of persistent symptoms after a trial of physical therapy. Primary outcomes were assessed according to Derkash’s classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and duration of hospital stay. Results: Between August 2004 and June 2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 men) with TOS. The mean age was 36.5 years (range: 15e68). Bilateral decompression was performed on 4 patients. The types were NTOS (n ¼ 19; 48%), VTOS (n ¼ 16; 40%), and ATOS (n ¼ 5; 12%). In addition to pain, the most common presenting symptom was numbness in NTOS, swelling in VTOS, and coolness in ATOS. A history of trauma was present in 22.2%. Two patients suffered from recurrent symptoms after previous transaxillary first rib resection for VTOS at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and first rib resection. The first rib resection was partial, through a supraclavicular only approach in NTOS and ATOS patients (60%) or complete, through a supra- and infraclavicular approach for VTOS patients (40%). Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow-up. Two patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths. Complications included pleural effusion requiring evacuation (n ¼ 4), neuropraxia (n ¼ 1), and lymph leak (n ¼ 1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean duration of hospital stay was 4.4 days. The mean follow-up was 10.3 months. Conclusions: In our experience, surgical paraclavicular decompression can provide safe and effective relief of NTOS, VTOS, and ATOS symptoms. Functional outcomes were excellent or good in the majority of patients, with minimal complications.
Presented at the 40th Annual Meeting of the Society for Clinical Vascular Surgery, Las Vegas, NV, March 13e17, 2012. Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School and Memorial Hermann Heart and Vascular Institute, Houston, TX. Correspondence to: Ali Azizzadeh, MD, FACS, Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School and Memorial Hermann Heart and Vascular Institute, 6400
Fannin, Suite 2850, Houston, TX 77030, USA; E-mail: Ali. [email protected] Ann Vasc Surg 2014; 28: 457–464 http://dx.doi.org/10.1016/j.avsg.2013.02.029 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: December 4, 2012; manuscript accepted: February 22, 2013; published online: December 30, 2013.
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Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery. Depending on the specific structure being affected, TOS is classified into 3 types: neurogenic (NTOS), venous (VTOS), and arterial (ATOS). NTOS is related to compression of the brachial plexus that may lead to pain, numbness, and weakness in the hand; this is by far the most common type of TOS.1 VTOS is caused by chronic compression and scarring of the subclavian vein leading to arm edema. Acute thrombosis of the subclavian vein, known as effort thrombosis or PageteSchroetter syndrome, develops in many patients with VTOS. ATOS is typically related to compression of the subclavian artery by osseous structures, with subsequent dilation, or aneurysmal degeneration resulting in thrombus formation and possible distal embolization to the arm and/or hand.1e6 The purpose of this study was to evaluate the outcomes of surgical decompression at a newly established center for TOS.
METHODS Patient Population A new program for the treatment of TOS was established in the Department of Cardiothoracic and Vascular Surgery at the University of Texas Medical School in Houston, TX. A prospective database consisting of patients undergoing surgical decompression was maintained. We compiled data on clinical presentation, diagnostic work-up, procedures performed, postoperative care, and outcomes. Based on these findings, TOS was characterized by type (i.e., NTOS, VTOS, and ATOS). Diagnosis of NTOS was based on a thorough history and clinical examination. We have found the elevated arm stress test to be a reliable tool in the diagnosis of NTOS. Nerve conduction tests were ordered. This was primarily done to rule out other conditions that mimic NTOS, such as ulnar nerve compression or carpal tunnel syndrome. All patients with a clinical diagnosis of NTOS were offered a trial of physical therapy. Surgical decompression was offered to candidates who had persistent symptoms after physical therapy. For patients with VTOS, in addition to a history and physical examination, a venogram was obtained in supine (arm adduction) and stress (arm abduction) positions. Patients presenting with acute PageteSchroetter syndrome underwent thrombolysis and were discharged with oral anticoagulation therapy. Open decompression was scheduled
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electively 4e6 weeks after the acute episode. Patients with ATOS, in addition to history and physical examination, underwent a 3-view chest radiograph (CXR) to rule out a cervical rib or other osseous anomalies. In addition, an arteriogram was obtained to evaluate for a subclavian artery aneurysm as well as the presence of distal emboli. Surgical Procedure All patients underwent surgical decompression using a paraclavicular approach. All patients with NTOS and the majority with ATOS had a supraclavicular incision only. Occasionally, patients with ATOS who had a large subclavian artery aneurysm required an additional infraclavicular incision for distal arterial control. In patients with VTOS, an additional infraclavicular incision was made for resection of the anterior segment of the first rib. After general anesthesia, the patient was placed in a supine position with a shoulder roll. The neck was extended and rotated to the opposite side of the procedure. A transverse incision was made 1 fingerbreadth above the clavicle, superior and inferior platysmal flapss were developed, and the lateral head of the sternocleidomastoid muscle was divided. The scalene fat pad was then dissected at the lateral border of the internal jugular vein and retracted laterally (Fig. 1A). The thoracic duct was divided in left-sided procedures. The anterior scalene muscle and scalenus minimus (when present) were circumferentially dissected and radically resected after protecting the phrenic nerve and subclavian artery (Fig. 1B). The anterior scalene muscle was circumferentially dissected from its insertion on the first rib to its origin at the C6 transverse process. The subclavian artery was further mobilized by the division of the thyrocervical trunk (Fig. 1C). Neurolysis of the brachial plexus (nerve roots C5eT1) was performed (Fig. 1D). A partial middle scalenectomy was then performed with care taken to preserve the tributaries of the long thoracic nerve. The first rib was then identified and the posterior portion (from the transverse process of the cervical spine to the tubercle) resected. Any cervical ribs present were also removed. In patients with VTOS, the anteromedial portion of the first rib was then accessed via a small infraclavicular incision (Fig. 2A) and the rib was resected (Fig. 2B). The subclavian vein was then mobilized from the supraclavicular approach and venolysis was performed, followed by an intraoperative venogram after decompression. In patients for whom significant stenosis or occlusion of the subclavian
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Fig. 1. (A) The supraclavicular incision is seen in this panel with the scalene fat pad being retracted laterally. (B) The phrenic nerve is identified and protected; the anterior scalene muscle is seen in this panel. (C) After removal of the anterior scalene, the subclavian artery is
mobilized. (D) Neurolysis of the brachial plexus is performed. The middle scalene and the posterior segment of the first rib are resected. (The subclavian artery here is encircled in a vessel loop).
Fig. 2. (A) Supraclavicular and infraclavicular incisions used for venous thoracic outlet syndrome (VTOS) decompression procedures. (B) The entire first rib is resected in VTOS procedures. (C) Preoperative venogram
of a patient with VTOS. (D) Postoperative venogram of a patient with VTOS after decompression and subclavian vein reconstruction.
vein was apparent, venous reconstruction was performed using the great saphenous vein. Satisfactory flow after subclavian vein repair was documented by complete venography (Fig. 2D). Patients with
VTOS were restarted on anticoagulation therapy on postoperative day (POD) 2. Anticoagulation was continued for 3 months, at which time a follow-up venography was performed.
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In patients with ATOS, the subclavian artery aneurysm was resected. The artery was reconstructed using an autogenous conduit whenever possible. A completion arteriogram was performed, and any evidence of previous distal embolization was treated with open thrombectomy through a brachial artery approach. Patients with ATOS and distal embolization were restarted on anticoagulation on POD 2. Anticoagulation therapy was continued for 3 months. After placement of a drain and closure of all incisions, patients were then extubated and taken to the postanesthesia care unit for recovery. Most patients had their drains removed at the time of discharge, which was typically on POD 4. Patients were seen in the clinic at 2, 6, and 12 weeks after discharge. Data Analysis Patients completed a postoperative survey to assess their recovery. Derkash’s classification was used to categorize primary outcomes as excellent, good, fair, or poor. Secondary outcomes included mortality, complications, and duration of hospital stay. The Student’s t-test was used to determine significance using a P value < 0.05. Descriptive statistics are presented as either mean ± standard error of the mean or a range of values when relevant.
RESULTS Thirty-six patients underwent 40 successful paraclavicular decompressions for TOS between August 2004 and June 2011. The average follow-up was 10.3 months. Based on a combination of history, physical examination, and diagnostic tests, patients were classified as having NTOS (n ¼ 19; 48%), VTOS (n ¼ 16; 40%), or ATOS (n ¼ 5; 12%). The incidence of each type of TOS varies from the overall population incidence because of referral bias and because these were the actual number of patients who underwent thoracic outlet decompression, not the number who were diagnosed and treated nonsurgically. Four patients underwent bilateral decompression. Table I shows the characterization of patient symptoms. The symptoms of pain and numbness were especially common in patients with NTOS (n ¼ 19) and ATOS (n ¼ 5; 100% each for pain; 100% and 80%, respectively, for numbness), while the chief complaint in patients with VTOS was swelling (n ¼ 15; 94%). Weakness (n ¼ 16; 84%) and fatigue (n ¼ 14; 74%) were also common for NTOS, while fatigue (n ¼ 4; 80%) and coolness (n ¼ 5; 100%)
Annals of Vascular Surgery
were common for ATOS. The only patients who had ulceration were those with ATOS (n ¼ 2; 40%). All patients reported some difficulty with motor function. Trauma was relatively uncommon, with relevant findings in 26% (n ¼ 5) of those with NTOS, 13% (n ¼ 2) of those with VTOS, and 20% (n ¼ 1) of those with ATOS. Only 2 patients (11%) reported a previous nerve procedure (ulnar nerve transposition and/or carpal tunnel release). Ten patients (63%) had previous thrombolysis, 2 (5%) with previous stent, and 2 (13%) with previous axillary rib resection at an outside institution. Patients with ATOS were more likely to have previous thrombolysis (n ¼ 4; 80%), previous stent (n ¼ 1; 20%), and stent graft placement (n ¼ 1; 20%). Diagnostic workup included CXR (36/40 encounters), computed tomography (CT; 9/40), magnetic resonance imaging (MRI; 17/40), electromyography (EMG; 17/40), nerve conduction study (17/40), arteriogram (10/40), and venogram (16/40). Patients with NTOS had CXR (79%), CT (21%), MRI (68%), EMG (84%), and/or nerve conduction study (79%). Two NTOS patients who were suspected of having some component of arterial involvement underwent an arteriogram (11%); no patients required venography. All nerve conduction studies and EMGs were normal for NTOS patients; none of these patients had a previous scalene block. An anterior and middle scalenectomy was performed in all 40 procedures. A cervical rib resection was performed in 7 patients. Cervical ribs were most commonly found in patients with ATOS (80%) compared to only 5% for NTOS. Resection of the first rib was completed in all patients with NTOS, 14 patients (88%) with VTOS, and 2 patients (40%) with ATOS. Two VTOS patients had previously undergone a transaxillary first rib resection. In ATOS patients where the resected cervical rib was identified as the cause of TOS, the first rib was spared. Brachial plexus neurolysis was completed in all patients. Thrombectomy (80%) and arterial reconstruction (100%) was necessary in ATOS, while venous reconstruction was necessary in 81% of VTOS patients. No patients with NTOS required vascular interventions (Table II). The overall duration of the procedure was 2.9 hours in NTOS, 4.0 hours in VTOS, and 3.6 hours in ATOS (P > 0.05). The duration of hospital stay varied between 3.6 days for NTOS, 5.5 days in VTOS, and 4.2 days in ATOS. Overall, only 2 patients were readmitted, both for shortness of breath. Two patients with NTOS were readmitted for shortness of breath (PODs 7 and 14, respectively). Neither patient required any intervention
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Thoracic outlet decompression outcomes 461
Table I. Clinical findings by thoracic outlet syndrome subtype out of 36 total patients treated using a paraclavicular approach over the course of 40 patient encountersa Symptom, n (%)
NTOS (n ¼ 19 encounters; 48%)
Pain Numbness Weakness Fatigue Headache Coolness Ulceration Swelling Difficulty with elevation (90 ) Difficulty with reaching overhead (180 ) Difficulty with lifting Difficulty with typing Difficulty with driving Difficulty using the telephone Difficulty shaving/combing Relevant trauma Previous physical therapy Previous thrombolysis Previous stenting Previous nerve procedure Previous rib removal Previous stent graft
19 19 16 14 9 8 0 8 19 18 17 10 13 15 17 5 19 0 0 2 0 0
(100) (100) (84) (74) (47) (42) (42) (100) (95) (89) (53) (68) (79) (89) (26) (100)
(11)
VTOS (n ¼ 16 encounters; 40%)
9 4 3 3 1 0 0 15 12 12 9 6 8 8 8 2 0 10 1 0 2 1
(56) (25) (19) (19) (6)
(94) (75) (75) (56) (38) (50) (50) (50) (13) (63) (6) (13) (6)
ATOS (n ¼ 5 encounters; 12%)
5 4 1 4 0 5 2 0 4 4 4 3 3 3 3 1 0 4 1 0 0 1
(100) (80) (20) (80) (100) (40) (80) (80) (80) (60) (60) (60) (60) (20) (80) (20)
(20)
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome. a The percentages in the first row are of the total number of encounters. All succeeding percentages are of the subset of thoracic outlet syndrome.
after excluding pneumothorax and pulmonary embolism, and both were discharged a few days later. Additional complications included pneumothorax (n ¼ 3), pleural effusion (n ¼ 13), hematoma (n ¼ 4), and brachial plexus injury (n ¼ 1), a neuropraxia secondary to retraction that resolved spontaneously (Table III). Most patients experienced resolution of their chief complaint and were back to their normal activities within 2e4 weeks after surgery, with only 1 patient lost to follow-up. Two patients reported incomplete symptom relief after paraclavicular decompression and underwent pectoralis minor decompression; they reported cessation of all clinically significant complaints after their subsequent procedure. TOS and pectoralis minor syndrome coexist in a small subset of patients with NTOS, and both present similarly. Our algorithm is to treat for the NTOS first to see if this will lead to a relief of symptoms. Continuing pain, weakness, paresthesias, and point tenderness over the pectoralis minor are indications for pectoralis minor decompression. All patients had their recovery measured using Derkash’s classification (Table IV). Fourteen patients in the NTOS group categorized their recovery as
‘‘excellent,’’ while 2 patients each rated their recovery as ‘‘good’’ and ‘‘fair.’’ Eleven patients in the VTOS group rated their recovery as ‘‘excellent,’’ 4 as ‘‘good,’’ and 1 ‘‘fair.’’ Four patients in the ATOS group experienced ‘‘excellent’’ results, and only 1 ‘‘fair’’ results. No patient in this study experienced ‘‘poor’’ results or any type of vascular injury.
DISCUSSION Surgical Approach Clagett7 described a posterior thoracotomy in 1962 and Roos8 described a transaxillary approach in 1966 for the treatment of TOS. The transaxillary approach rose to prominence in the 1970se80s but was later criticized for a higher than usual incidence of nerve injury.9,10 A combined supraclavicular and transaxillary approach was briefly advocated in the mid-1980s, but this was replaced by a purely supraclavicular approach pioneered by Reilly and Stoney.11,12 Thompson13 and Thompson et al.14 described the paraclavicular approach as an alternative to the supraclavicular approach, especially in patients with VTOS.
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Table II. Operative intervention by thoracic outlet syndrome subtype out of 40 total encounters Operative intervention, n (%)
Anterior scalenectomy Middle scalenectomy Cervical rib resection First rib resection Neurolysis of brachial plexus Angiolysis Thrombectomy Arterial reconstruction Venous reconstruction Patch angioplasty Arterial or venous bypass
Table III. Overall duration of procedure, duration of hospital stay, and incidence of complications out of 40 total encounters
NTOS
VTOS
ATOS
19 19 1 19 19
16 16 2 14 15
(100) (100) (13) (88) (94)
5 5 4 2 5
(100) (100) (80) (40) (100)
13 0 0 13 8 5
(81)
5 4 5 0 0 5
(100) (80) (100)
(100) (100) (5) (100) (100)
3 (16) 0 0 0 0 0
(81) (50) (31)
(100)
Duration of operation (hrs) Duration of hospital stay (days) Readmitted within 30 days, n (%) Pneumothorax, n (%) Pleural effusion, n (%) Hematoma with evacuation, n (%) Wound infection, n (%) Brachial plexus injury, n (%) Phrenic nerve injury, n (%) Long thoracic nerve injury, n (%) Lymph leak, n (%)
NTOS
VTOS
ATOS
2.9 3.6 2 (11)
4.0 5.5 0
3.6 4.2 0
1 (5) 7 (37) 1 (5)
1 (6) 6 (38) 3 (19)
1 (20) 0 0
0 0 0 0
0 0 0 0
0 1 (20) 0 0
0
0
0
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome.
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome.
Compared to the other approaches, we believe that the paraclavicular approach to TOS offers clearer views of the brachial plexus and major vascular structures in an ample surgical field, affords easy accessibility to cervical and aberrant first ribs, permits complete resection of the scalene muscles and associated scar tissue, and allows for a full brachial plexus neurolysis. In addition, arterial and venous reconstruction can be performed with ease under direct visualization. In our series, most patients with NTOS and ATOS had a supraclavicular incision only. Patients with VTOS had an additional infraclavicular incision for resection of the anterior segment of the first rib.
Table IV. Functional outcomes according to type of thoracic outlet syndrome categorized using Derkash’s classification
NTOS Controversy remains over the diagnosis and management of NTOS. We consider NTOS a clinical diagnosis that is primarily based on history and physical examination. Most of the additional diagnostic testing was performed to rule out other conditions that mimic NTOS, such as ulnar nerve compression or carpal tunnel syndrome. In fact, all EMG and nerve conduction studies in our NTOS group were normal. Arteriograms were performed selectively to rule out an arterial component. We have found that a good clinical examination is often sufficient to differentiate NTOS from the other forms of TOS. All patients diagnosed with NTOS underwent a trial of physical therapy before being considered for surgery. Patients who continued to have clinically significant and lifestyle-limiting symptoms
Derkash’s classification
NTOS, n (%) VTOS, n (%) ATOS, n (%)
Excellent
Good
Fair
Poor
14 (78) 11 (69) 4 (80)
2 (11) 4 (25) 0
2 (11) 1 (6.3) 1 (20)
0 0 0
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome.
after physical therapy were offered surgical decompression. Similar selective protocols for surgical treatment of NTOS have been advocated by others.4,15,16 Our results mirror what has previously been reported by other centers.3e5 Out of the 19 patients who underwent decompression for NTOS, all but 2 (89%) reported a resolution in their symptoms and improvement in muscle strength at follow-up. One of those patients reported about 80% improvement in symptoms, while the other patient developed new right upper extremity symptoms that were attributed to recurrent scarring. In the current series, the operative time and duration of hospital stay were shorter for NTOS when compared to VTOS and ATOS. This is consistent with a more complex decompression procedure and vascular reconstruction that is often required for vasculogenic TOS (i.e., VTOS and ATOS).
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The functional outcomes reported by NTOS patients who underwent paraclavicular decompression indicate that most patients can expect total or near-total resolution of their symptoms and improvement in their range of motion after surgery. Similar outcomes have been reported by Chandra et al.4 for NTOS decompression, with 90% of the patients experiencing resolution of their symptoms at 1 year of follow-up. A high index of suspicion for complications, such as pneumothorax, hematoma, and pleural effusions, can help reduce the risk profile of this procedure. Our results, combined with other recent studies, appear to indicate that offering carefully selected patients with NTOS a surgical option can provide long-term and effective relief.3e5 VTOS Patients were selected for surgery on the basis of their history, symptoms, and diagnostic imaging studies. The majority of patients reported arm swelling (94%), difficulty with arm elevation (75%), difficulty with reaching overhead (75%), and other motor defects. All patients with VTOS had a CXR and venogram. Patients presenting with effort thrombosis or PageteSchroetter syndrome underwent catheter-directed thrombolysis as first-line therapy.17,18 They were subsequently discharged on oral anticoagulation followed by elective formal surgical decompression at 4e6 weeks. In our study, 10 of 16 patients (63%) had previously undergone thrombolysis, 1 patient had a previous stent (6%), and 2 (13%) had previous axillary rib resection. We do not believe that there is a role for stent placement in patients with VTOS, because the primary cause is external compression of the vein. VTOS patients underwent supraclavicular decompression similar to those with NTOS. In addition, VTOS patients required an infraclavicular incision for resection of the anterior segment of the first rib (paraclavicular approach). Two patients had previous transaxillary rib resections and did not require this portion of the surgery. Based on the intraoperative venogram after surgical decompression and venolysis, the majority (81%) of the VTOS group required formal venous reconstruction. In half the cases (50%), this consisted of a vein patch angioplasty, while some (31%) required a bypass. There were no readmissions within 30 days of surgery. Major complications included 6 patients (38%) with clinically insignificant pleural effusion and 3 (19%) with a hematoma that required evacuation. We believe the high reexploration rate was related to early postoperative anticoagulation.
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While early anticoagulation carries a high risk of bleeding, it is often necessary to maintain patency in the setting of a fresh venous reconstruction. In our view, the initiation of the postoperative anticoagulation has to be tailored to the specific patient and based on the complexity of the procedure, the presence and type of venous reconstruction (patch versus bypass), and the amount of drain output. Most patients are started on an intravenous heparin drip on POD 2. Based on the findings of this study, however, we may delay the initiation of anticoagulation selectively. Functional outcomes based on Derkash’s classification were similar to the results seen in the NTOS group. About 94% of the VTOS patients experienced ‘‘excellent’’ or ‘‘good’’ functional outcomes, indicating that the paraclavicular decompression appears to be a safe and effective means for the treatment of this subtype. ATOS Only 5 of the 40 (13%) encounters in our study were for ATOS, and similar to the report by Coote19 in 1861, all of our patients also had either a cervical or anomalous first rib. While about 13% of our encounters were for ATOS compared to the 1e6% reported in the literature, the bias in our study is caused by referral patterns and the fact that only patients who underwent surgery were included in the sample population.6,20e22 All 5 patients with ATOS reported pain and coolness of the affected extremity. Four also reported numbness, fatigue, and a limited range of motion. Two patients had extremity ulcers consistent with distal embolism secondary to a subclavian artery aneurysm. Four patients had previous thrombolysis before formal decompression. Our diagnosis was confirmed by CXR and arteriograms in all 5 patients. All ATOS patients underwent supraclavicular decompression with anterior and middle scalenectomy. One patient required an additional infraclavicular incision to obtain distal control of a large subclavian artery aneurysm. Four patients had resection of a cervical rib and 2 had a partial first rib resection. We were able to spare the first rib in selected patients with ATOS in whom resection of a cervical rib provided adequate decompression. All 5 patients also had limited neurolysis of the brachial plexus, angiolysis, and arterial reconstruction with bypass. We preferentially used autologous conduits when possible. We have also successfully used prosthetic conduits, such as Dacron (DuPont, Wilmington, NC) or polytetrafluoroethylene when suitable autologous alternatives are unavailable. In our series, 1 patient experienced a pneumothorax
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during surgery because of central venous catheter placement and required a chest tube to be placed intraoperatively. This patient also had neuropraxia, likely related to retraction that resolved spontaneously. The other 4 patients had an uneventful recovery, with full resolution of their symptoms at follow-up. Four patients reported ‘‘excellent’’ results. Overall, it appears that supraclavicular decompression appears to be a safe and effective means of treating ATOS.
CONCLUSION Paraclavicular decompression is a safe and effective means of treating all forms of TOS. Functional outcomes are rated as ‘‘good’’ or ‘‘excellent’’ in the majority of patients, with few serious complications after the procedure. Properly selected patients can be offered paraclavicular decompression as an option for resolving their symptoms. REFERENCES 1. Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med 2009;11:176e83. 2. Melby SJ, Vedantham S, Narra VR, et al. Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome). J Vasc Surg 2008;47:809e21. 3. Thompson RW, Driskill MR. Neurovascular problems in the athlete’s shoulder. Clin Sports Med 2008;27:789e802. 4. Chandra V, Olcott C IV, Lee JT. Early results of a highly selective algorithm for surgery on patients with neurogenic thoracic outlet syndrome. J Vasc Surg 2011;54:1698e705. 5. Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg 2009;49:630e5. 6. Urschel HC Jr, Kourlis H Jr. Thoracic outlet syndrome: a 50year experience at Baylor University Medical Center. Proc Bayl Univ Med Cent 2007;20:125e35.
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7. Clagett OT. Presidential address: research and proresearch. J Thorac Cardiovasc Surg 1962;44:153e66. 8. Roos DB. Transaxillary approach for first rib resection to relieve thoracic outlet syndrome. Ann Surg 1966;163:354e8. 9. Dale A. Thoracic outlet compression syndrome: critique in 1982. Arch Surg 1982;117:1437e45. 10. Cikrit DF, Haefner R, Nichols WK, et al. Transaxillary or supraclavicular decompression for the thoracic outlet syndrome: a comparison of the risks and benefits. Am Surg 1989;55:347e52. 11. Qvarfordt PG, Ehrenfeld WK, Stoney RJ. Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome: a combined approach. Am J Surg 1984;148:111e6. 12. Reilly LM, Stoney RJ. Supraclavicular approach for thoracic outlet decompression. J Vasc Surg 1988;8:329e34. 13. Thompson R. Venous thoracic outlet syndrome: paraclavicular approach. Opertaive Techniques in General Surgery 2008;10:113e21. 14. Thompson JF, Winterborn RJ, Bays S, et al. Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol 2011;34:903e10. 15. Wilbourn AJ. The thoracic outlet syndrome is overdiagnosed. Arch Neurol 1990;47:328e30. 16. Wilbourn AJ. Thoracic outlet syndromes: a plea for conservatism. Neurosurg Clin N Am 1991;2:235e45. 17. Druy EM, Trout HH 3rd, Giordano JM, et al. Lytic therapy in the treatment of axillary and subclavian vein thrombosis. J Vasc Surg 1985;2:821e7. 18. Lee JT, Karwowski JK, Harris EJ, et al. Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg 2006;43: 1236e43. 19. Coote H. Exostosis of the transverse process of the seventh cervical vertebra, surrounded by blood vessels and nerves: successful removal. Lancet 1861;1:360e1. 20. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg 1992;16:534e45. 21. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg 2007;46:601e4. 22. Criado E, Berguer R, Greenfield L. The spectrum of arterial compression at the thoracic outlet. J Vasc Surg 2010;52: 406e11.
Background: Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery, resulting in neurogenic (NTOS), venous (VTOS), and arterial (ATOS) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of paraclavicular surgical decompression for TOS. Methods: A prospective analysis of patients who underwent surgical decompression for TOS at a newly established center was performed. Diagnosis of TOS was based on clinical history, a physical examination, and additional diagnostic studies. The indication for surgery in patients diagnosed with NTOS was the presence of persistent symptoms after a trial of physical therapy. Primary outcomes were assessed according to Derkash’s classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and duration of hospital stay. Results: Between August 2004 and June 2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 men) with TOS. The mean age was 36.5 years (range: 15e68). Bilateral decompression was performed on 4 patients. The types were NTOS (n ¼ 19; 48%), VTOS (n ¼ 16; 40%), and ATOS (n ¼ 5; 12%). In addition to pain, the most common presenting symptom was numbness in NTOS, swelling in VTOS, and coolness in ATOS. A history of trauma was present in 22.2%. Two patients suffered from recurrent symptoms after previous transaxillary first rib resection for VTOS at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and first rib resection. The first rib resection was partial, through a supraclavicular only approach in NTOS and ATOS patients (60%) or complete, through a supra- and infraclavicular approach for VTOS patients (40%). Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow-up. Two patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths. Complications included pleural effusion requiring evacuation (n ¼ 4), neuropraxia (n ¼ 1), and lymph leak (n ¼ 1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean duration of hospital stay was 4.4 days. The mean follow-up was 10.3 months. Conclusions: In our experience, surgical paraclavicular decompression can provide safe and effective relief of NTOS, VTOS, and ATOS symptoms. Functional outcomes were excellent or good in the majority of patients, with minimal complications.
Presented at the 40th Annual Meeting of the Society for Clinical Vascular Surgery, Las Vegas, NV, March 13e17, 2012. Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School and Memorial Hermann Heart and Vascular Institute, Houston, TX. Correspondence to: Ali Azizzadeh, MD, FACS, Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School and Memorial Hermann Heart and Vascular Institute, 6400
Fannin, Suite 2850, Houston, TX 77030, USA; E-mail: Ali. [email protected] Ann Vasc Surg 2014; 28: 457–464 http://dx.doi.org/10.1016/j.avsg.2013.02.029 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: December 4, 2012; manuscript accepted: February 22, 2013; published online: December 30, 2013.
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Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery. Depending on the specific structure being affected, TOS is classified into 3 types: neurogenic (NTOS), venous (VTOS), and arterial (ATOS). NTOS is related to compression of the brachial plexus that may lead to pain, numbness, and weakness in the hand; this is by far the most common type of TOS.1 VTOS is caused by chronic compression and scarring of the subclavian vein leading to arm edema. Acute thrombosis of the subclavian vein, known as effort thrombosis or PageteSchroetter syndrome, develops in many patients with VTOS. ATOS is typically related to compression of the subclavian artery by osseous structures, with subsequent dilation, or aneurysmal degeneration resulting in thrombus formation and possible distal embolization to the arm and/or hand.1e6 The purpose of this study was to evaluate the outcomes of surgical decompression at a newly established center for TOS.
METHODS Patient Population A new program for the treatment of TOS was established in the Department of Cardiothoracic and Vascular Surgery at the University of Texas Medical School in Houston, TX. A prospective database consisting of patients undergoing surgical decompression was maintained. We compiled data on clinical presentation, diagnostic work-up, procedures performed, postoperative care, and outcomes. Based on these findings, TOS was characterized by type (i.e., NTOS, VTOS, and ATOS). Diagnosis of NTOS was based on a thorough history and clinical examination. We have found the elevated arm stress test to be a reliable tool in the diagnosis of NTOS. Nerve conduction tests were ordered. This was primarily done to rule out other conditions that mimic NTOS, such as ulnar nerve compression or carpal tunnel syndrome. All patients with a clinical diagnosis of NTOS were offered a trial of physical therapy. Surgical decompression was offered to candidates who had persistent symptoms after physical therapy. For patients with VTOS, in addition to a history and physical examination, a venogram was obtained in supine (arm adduction) and stress (arm abduction) positions. Patients presenting with acute PageteSchroetter syndrome underwent thrombolysis and were discharged with oral anticoagulation therapy. Open decompression was scheduled
Annals of Vascular Surgery
electively 4e6 weeks after the acute episode. Patients with ATOS, in addition to history and physical examination, underwent a 3-view chest radiograph (CXR) to rule out a cervical rib or other osseous anomalies. In addition, an arteriogram was obtained to evaluate for a subclavian artery aneurysm as well as the presence of distal emboli. Surgical Procedure All patients underwent surgical decompression using a paraclavicular approach. All patients with NTOS and the majority with ATOS had a supraclavicular incision only. Occasionally, patients with ATOS who had a large subclavian artery aneurysm required an additional infraclavicular incision for distal arterial control. In patients with VTOS, an additional infraclavicular incision was made for resection of the anterior segment of the first rib. After general anesthesia, the patient was placed in a supine position with a shoulder roll. The neck was extended and rotated to the opposite side of the procedure. A transverse incision was made 1 fingerbreadth above the clavicle, superior and inferior platysmal flapss were developed, and the lateral head of the sternocleidomastoid muscle was divided. The scalene fat pad was then dissected at the lateral border of the internal jugular vein and retracted laterally (Fig. 1A). The thoracic duct was divided in left-sided procedures. The anterior scalene muscle and scalenus minimus (when present) were circumferentially dissected and radically resected after protecting the phrenic nerve and subclavian artery (Fig. 1B). The anterior scalene muscle was circumferentially dissected from its insertion on the first rib to its origin at the C6 transverse process. The subclavian artery was further mobilized by the division of the thyrocervical trunk (Fig. 1C). Neurolysis of the brachial plexus (nerve roots C5eT1) was performed (Fig. 1D). A partial middle scalenectomy was then performed with care taken to preserve the tributaries of the long thoracic nerve. The first rib was then identified and the posterior portion (from the transverse process of the cervical spine to the tubercle) resected. Any cervical ribs present were also removed. In patients with VTOS, the anteromedial portion of the first rib was then accessed via a small infraclavicular incision (Fig. 2A) and the rib was resected (Fig. 2B). The subclavian vein was then mobilized from the supraclavicular approach and venolysis was performed, followed by an intraoperative venogram after decompression. In patients for whom significant stenosis or occlusion of the subclavian
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Fig. 1. (A) The supraclavicular incision is seen in this panel with the scalene fat pad being retracted laterally. (B) The phrenic nerve is identified and protected; the anterior scalene muscle is seen in this panel. (C) After removal of the anterior scalene, the subclavian artery is
mobilized. (D) Neurolysis of the brachial plexus is performed. The middle scalene and the posterior segment of the first rib are resected. (The subclavian artery here is encircled in a vessel loop).
Fig. 2. (A) Supraclavicular and infraclavicular incisions used for venous thoracic outlet syndrome (VTOS) decompression procedures. (B) The entire first rib is resected in VTOS procedures. (C) Preoperative venogram
of a patient with VTOS. (D) Postoperative venogram of a patient with VTOS after decompression and subclavian vein reconstruction.
vein was apparent, venous reconstruction was performed using the great saphenous vein. Satisfactory flow after subclavian vein repair was documented by complete venography (Fig. 2D). Patients with
VTOS were restarted on anticoagulation therapy on postoperative day (POD) 2. Anticoagulation was continued for 3 months, at which time a follow-up venography was performed.
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In patients with ATOS, the subclavian artery aneurysm was resected. The artery was reconstructed using an autogenous conduit whenever possible. A completion arteriogram was performed, and any evidence of previous distal embolization was treated with open thrombectomy through a brachial artery approach. Patients with ATOS and distal embolization were restarted on anticoagulation on POD 2. Anticoagulation therapy was continued for 3 months. After placement of a drain and closure of all incisions, patients were then extubated and taken to the postanesthesia care unit for recovery. Most patients had their drains removed at the time of discharge, which was typically on POD 4. Patients were seen in the clinic at 2, 6, and 12 weeks after discharge. Data Analysis Patients completed a postoperative survey to assess their recovery. Derkash’s classification was used to categorize primary outcomes as excellent, good, fair, or poor. Secondary outcomes included mortality, complications, and duration of hospital stay. The Student’s t-test was used to determine significance using a P value < 0.05. Descriptive statistics are presented as either mean ± standard error of the mean or a range of values when relevant.
RESULTS Thirty-six patients underwent 40 successful paraclavicular decompressions for TOS between August 2004 and June 2011. The average follow-up was 10.3 months. Based on a combination of history, physical examination, and diagnostic tests, patients were classified as having NTOS (n ¼ 19; 48%), VTOS (n ¼ 16; 40%), or ATOS (n ¼ 5; 12%). The incidence of each type of TOS varies from the overall population incidence because of referral bias and because these were the actual number of patients who underwent thoracic outlet decompression, not the number who were diagnosed and treated nonsurgically. Four patients underwent bilateral decompression. Table I shows the characterization of patient symptoms. The symptoms of pain and numbness were especially common in patients with NTOS (n ¼ 19) and ATOS (n ¼ 5; 100% each for pain; 100% and 80%, respectively, for numbness), while the chief complaint in patients with VTOS was swelling (n ¼ 15; 94%). Weakness (n ¼ 16; 84%) and fatigue (n ¼ 14; 74%) were also common for NTOS, while fatigue (n ¼ 4; 80%) and coolness (n ¼ 5; 100%)
Annals of Vascular Surgery
were common for ATOS. The only patients who had ulceration were those with ATOS (n ¼ 2; 40%). All patients reported some difficulty with motor function. Trauma was relatively uncommon, with relevant findings in 26% (n ¼ 5) of those with NTOS, 13% (n ¼ 2) of those with VTOS, and 20% (n ¼ 1) of those with ATOS. Only 2 patients (11%) reported a previous nerve procedure (ulnar nerve transposition and/or carpal tunnel release). Ten patients (63%) had previous thrombolysis, 2 (5%) with previous stent, and 2 (13%) with previous axillary rib resection at an outside institution. Patients with ATOS were more likely to have previous thrombolysis (n ¼ 4; 80%), previous stent (n ¼ 1; 20%), and stent graft placement (n ¼ 1; 20%). Diagnostic workup included CXR (36/40 encounters), computed tomography (CT; 9/40), magnetic resonance imaging (MRI; 17/40), electromyography (EMG; 17/40), nerve conduction study (17/40), arteriogram (10/40), and venogram (16/40). Patients with NTOS had CXR (79%), CT (21%), MRI (68%), EMG (84%), and/or nerve conduction study (79%). Two NTOS patients who were suspected of having some component of arterial involvement underwent an arteriogram (11%); no patients required venography. All nerve conduction studies and EMGs were normal for NTOS patients; none of these patients had a previous scalene block. An anterior and middle scalenectomy was performed in all 40 procedures. A cervical rib resection was performed in 7 patients. Cervical ribs were most commonly found in patients with ATOS (80%) compared to only 5% for NTOS. Resection of the first rib was completed in all patients with NTOS, 14 patients (88%) with VTOS, and 2 patients (40%) with ATOS. Two VTOS patients had previously undergone a transaxillary first rib resection. In ATOS patients where the resected cervical rib was identified as the cause of TOS, the first rib was spared. Brachial plexus neurolysis was completed in all patients. Thrombectomy (80%) and arterial reconstruction (100%) was necessary in ATOS, while venous reconstruction was necessary in 81% of VTOS patients. No patients with NTOS required vascular interventions (Table II). The overall duration of the procedure was 2.9 hours in NTOS, 4.0 hours in VTOS, and 3.6 hours in ATOS (P > 0.05). The duration of hospital stay varied between 3.6 days for NTOS, 5.5 days in VTOS, and 4.2 days in ATOS. Overall, only 2 patients were readmitted, both for shortness of breath. Two patients with NTOS were readmitted for shortness of breath (PODs 7 and 14, respectively). Neither patient required any intervention
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Table I. Clinical findings by thoracic outlet syndrome subtype out of 36 total patients treated using a paraclavicular approach over the course of 40 patient encountersa Symptom, n (%)
NTOS (n ¼ 19 encounters; 48%)
Pain Numbness Weakness Fatigue Headache Coolness Ulceration Swelling Difficulty with elevation (90 ) Difficulty with reaching overhead (180 ) Difficulty with lifting Difficulty with typing Difficulty with driving Difficulty using the telephone Difficulty shaving/combing Relevant trauma Previous physical therapy Previous thrombolysis Previous stenting Previous nerve procedure Previous rib removal Previous stent graft
19 19 16 14 9 8 0 8 19 18 17 10 13 15 17 5 19 0 0 2 0 0
(100) (100) (84) (74) (47) (42) (42) (100) (95) (89) (53) (68) (79) (89) (26) (100)
(11)
VTOS (n ¼ 16 encounters; 40%)
9 4 3 3 1 0 0 15 12 12 9 6 8 8 8 2 0 10 1 0 2 1
(56) (25) (19) (19) (6)
(94) (75) (75) (56) (38) (50) (50) (50) (13) (63) (6) (13) (6)
ATOS (n ¼ 5 encounters; 12%)
5 4 1 4 0 5 2 0 4 4 4 3 3 3 3 1 0 4 1 0 0 1
(100) (80) (20) (80) (100) (40) (80) (80) (80) (60) (60) (60) (60) (20) (80) (20)
(20)
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome. a The percentages in the first row are of the total number of encounters. All succeeding percentages are of the subset of thoracic outlet syndrome.
after excluding pneumothorax and pulmonary embolism, and both were discharged a few days later. Additional complications included pneumothorax (n ¼ 3), pleural effusion (n ¼ 13), hematoma (n ¼ 4), and brachial plexus injury (n ¼ 1), a neuropraxia secondary to retraction that resolved spontaneously (Table III). Most patients experienced resolution of their chief complaint and were back to their normal activities within 2e4 weeks after surgery, with only 1 patient lost to follow-up. Two patients reported incomplete symptom relief after paraclavicular decompression and underwent pectoralis minor decompression; they reported cessation of all clinically significant complaints after their subsequent procedure. TOS and pectoralis minor syndrome coexist in a small subset of patients with NTOS, and both present similarly. Our algorithm is to treat for the NTOS first to see if this will lead to a relief of symptoms. Continuing pain, weakness, paresthesias, and point tenderness over the pectoralis minor are indications for pectoralis minor decompression. All patients had their recovery measured using Derkash’s classification (Table IV). Fourteen patients in the NTOS group categorized their recovery as
‘‘excellent,’’ while 2 patients each rated their recovery as ‘‘good’’ and ‘‘fair.’’ Eleven patients in the VTOS group rated their recovery as ‘‘excellent,’’ 4 as ‘‘good,’’ and 1 ‘‘fair.’’ Four patients in the ATOS group experienced ‘‘excellent’’ results, and only 1 ‘‘fair’’ results. No patient in this study experienced ‘‘poor’’ results or any type of vascular injury.
DISCUSSION Surgical Approach Clagett7 described a posterior thoracotomy in 1962 and Roos8 described a transaxillary approach in 1966 for the treatment of TOS. The transaxillary approach rose to prominence in the 1970se80s but was later criticized for a higher than usual incidence of nerve injury.9,10 A combined supraclavicular and transaxillary approach was briefly advocated in the mid-1980s, but this was replaced by a purely supraclavicular approach pioneered by Reilly and Stoney.11,12 Thompson13 and Thompson et al.14 described the paraclavicular approach as an alternative to the supraclavicular approach, especially in patients with VTOS.
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Table II. Operative intervention by thoracic outlet syndrome subtype out of 40 total encounters Operative intervention, n (%)
Anterior scalenectomy Middle scalenectomy Cervical rib resection First rib resection Neurolysis of brachial plexus Angiolysis Thrombectomy Arterial reconstruction Venous reconstruction Patch angioplasty Arterial or venous bypass
Table III. Overall duration of procedure, duration of hospital stay, and incidence of complications out of 40 total encounters
NTOS
VTOS
ATOS
19 19 1 19 19
16 16 2 14 15
(100) (100) (13) (88) (94)
5 5 4 2 5
(100) (100) (80) (40) (100)
13 0 0 13 8 5
(81)
5 4 5 0 0 5
(100) (80) (100)
(100) (100) (5) (100) (100)
3 (16) 0 0 0 0 0
(81) (50) (31)
(100)
Duration of operation (hrs) Duration of hospital stay (days) Readmitted within 30 days, n (%) Pneumothorax, n (%) Pleural effusion, n (%) Hematoma with evacuation, n (%) Wound infection, n (%) Brachial plexus injury, n (%) Phrenic nerve injury, n (%) Long thoracic nerve injury, n (%) Lymph leak, n (%)
NTOS
VTOS
ATOS
2.9 3.6 2 (11)
4.0 5.5 0
3.6 4.2 0
1 (5) 7 (37) 1 (5)
1 (6) 6 (38) 3 (19)
1 (20) 0 0
0 0 0 0
0 0 0 0
0 1 (20) 0 0
0
0
0
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome.
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome.
Compared to the other approaches, we believe that the paraclavicular approach to TOS offers clearer views of the brachial plexus and major vascular structures in an ample surgical field, affords easy accessibility to cervical and aberrant first ribs, permits complete resection of the scalene muscles and associated scar tissue, and allows for a full brachial plexus neurolysis. In addition, arterial and venous reconstruction can be performed with ease under direct visualization. In our series, most patients with NTOS and ATOS had a supraclavicular incision only. Patients with VTOS had an additional infraclavicular incision for resection of the anterior segment of the first rib.
Table IV. Functional outcomes according to type of thoracic outlet syndrome categorized using Derkash’s classification
NTOS Controversy remains over the diagnosis and management of NTOS. We consider NTOS a clinical diagnosis that is primarily based on history and physical examination. Most of the additional diagnostic testing was performed to rule out other conditions that mimic NTOS, such as ulnar nerve compression or carpal tunnel syndrome. In fact, all EMG and nerve conduction studies in our NTOS group were normal. Arteriograms were performed selectively to rule out an arterial component. We have found that a good clinical examination is often sufficient to differentiate NTOS from the other forms of TOS. All patients diagnosed with NTOS underwent a trial of physical therapy before being considered for surgery. Patients who continued to have clinically significant and lifestyle-limiting symptoms
Derkash’s classification
NTOS, n (%) VTOS, n (%) ATOS, n (%)
Excellent
Good
Fair
Poor
14 (78) 11 (69) 4 (80)
2 (11) 4 (25) 0
2 (11) 1 (6.3) 1 (20)
0 0 0
ATOS, Arterial thoracic outlet syndrome; NTOS, neurogenic thoracic outlet syndrome; VTOS, venous thoracic outlet syndrome.
after physical therapy were offered surgical decompression. Similar selective protocols for surgical treatment of NTOS have been advocated by others.4,15,16 Our results mirror what has previously been reported by other centers.3e5 Out of the 19 patients who underwent decompression for NTOS, all but 2 (89%) reported a resolution in their symptoms and improvement in muscle strength at follow-up. One of those patients reported about 80% improvement in symptoms, while the other patient developed new right upper extremity symptoms that were attributed to recurrent scarring. In the current series, the operative time and duration of hospital stay were shorter for NTOS when compared to VTOS and ATOS. This is consistent with a more complex decompression procedure and vascular reconstruction that is often required for vasculogenic TOS (i.e., VTOS and ATOS).
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The functional outcomes reported by NTOS patients who underwent paraclavicular decompression indicate that most patients can expect total or near-total resolution of their symptoms and improvement in their range of motion after surgery. Similar outcomes have been reported by Chandra et al.4 for NTOS decompression, with 90% of the patients experiencing resolution of their symptoms at 1 year of follow-up. A high index of suspicion for complications, such as pneumothorax, hematoma, and pleural effusions, can help reduce the risk profile of this procedure. Our results, combined with other recent studies, appear to indicate that offering carefully selected patients with NTOS a surgical option can provide long-term and effective relief.3e5 VTOS Patients were selected for surgery on the basis of their history, symptoms, and diagnostic imaging studies. The majority of patients reported arm swelling (94%), difficulty with arm elevation (75%), difficulty with reaching overhead (75%), and other motor defects. All patients with VTOS had a CXR and venogram. Patients presenting with effort thrombosis or PageteSchroetter syndrome underwent catheter-directed thrombolysis as first-line therapy.17,18 They were subsequently discharged on oral anticoagulation followed by elective formal surgical decompression at 4e6 weeks. In our study, 10 of 16 patients (63%) had previously undergone thrombolysis, 1 patient had a previous stent (6%), and 2 (13%) had previous axillary rib resection. We do not believe that there is a role for stent placement in patients with VTOS, because the primary cause is external compression of the vein. VTOS patients underwent supraclavicular decompression similar to those with NTOS. In addition, VTOS patients required an infraclavicular incision for resection of the anterior segment of the first rib (paraclavicular approach). Two patients had previous transaxillary rib resections and did not require this portion of the surgery. Based on the intraoperative venogram after surgical decompression and venolysis, the majority (81%) of the VTOS group required formal venous reconstruction. In half the cases (50%), this consisted of a vein patch angioplasty, while some (31%) required a bypass. There were no readmissions within 30 days of surgery. Major complications included 6 patients (38%) with clinically insignificant pleural effusion and 3 (19%) with a hematoma that required evacuation. We believe the high reexploration rate was related to early postoperative anticoagulation.
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While early anticoagulation carries a high risk of bleeding, it is often necessary to maintain patency in the setting of a fresh venous reconstruction. In our view, the initiation of the postoperative anticoagulation has to be tailored to the specific patient and based on the complexity of the procedure, the presence and type of venous reconstruction (patch versus bypass), and the amount of drain output. Most patients are started on an intravenous heparin drip on POD 2. Based on the findings of this study, however, we may delay the initiation of anticoagulation selectively. Functional outcomes based on Derkash’s classification were similar to the results seen in the NTOS group. About 94% of the VTOS patients experienced ‘‘excellent’’ or ‘‘good’’ functional outcomes, indicating that the paraclavicular decompression appears to be a safe and effective means for the treatment of this subtype. ATOS Only 5 of the 40 (13%) encounters in our study were for ATOS, and similar to the report by Coote19 in 1861, all of our patients also had either a cervical or anomalous first rib. While about 13% of our encounters were for ATOS compared to the 1e6% reported in the literature, the bias in our study is caused by referral patterns and the fact that only patients who underwent surgery were included in the sample population.6,20e22 All 5 patients with ATOS reported pain and coolness of the affected extremity. Four also reported numbness, fatigue, and a limited range of motion. Two patients had extremity ulcers consistent with distal embolism secondary to a subclavian artery aneurysm. Four patients had previous thrombolysis before formal decompression. Our diagnosis was confirmed by CXR and arteriograms in all 5 patients. All ATOS patients underwent supraclavicular decompression with anterior and middle scalenectomy. One patient required an additional infraclavicular incision to obtain distal control of a large subclavian artery aneurysm. Four patients had resection of a cervical rib and 2 had a partial first rib resection. We were able to spare the first rib in selected patients with ATOS in whom resection of a cervical rib provided adequate decompression. All 5 patients also had limited neurolysis of the brachial plexus, angiolysis, and arterial reconstruction with bypass. We preferentially used autologous conduits when possible. We have also successfully used prosthetic conduits, such as Dacron (DuPont, Wilmington, NC) or polytetrafluoroethylene when suitable autologous alternatives are unavailable. In our series, 1 patient experienced a pneumothorax
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during surgery because of central venous catheter placement and required a chest tube to be placed intraoperatively. This patient also had neuropraxia, likely related to retraction that resolved spontaneously. The other 4 patients had an uneventful recovery, with full resolution of their symptoms at follow-up. Four patients reported ‘‘excellent’’ results. Overall, it appears that supraclavicular decompression appears to be a safe and effective means of treating ATOS.
CONCLUSION Paraclavicular decompression is a safe and effective means of treating all forms of TOS. Functional outcomes are rated as ‘‘good’’ or ‘‘excellent’’ in the majority of patients, with few serious complications after the procedure. Properly selected patients can be offered paraclavicular decompression as an option for resolving their symptoms. REFERENCES 1. Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med 2009;11:176e83. 2. Melby SJ, Vedantham S, Narra VR, et al. Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome). J Vasc Surg 2008;47:809e21. 3. Thompson RW, Driskill MR. Neurovascular problems in the athlete’s shoulder. Clin Sports Med 2008;27:789e802. 4. Chandra V, Olcott C IV, Lee JT. Early results of a highly selective algorithm for surgery on patients with neurogenic thoracic outlet syndrome. J Vasc Surg 2011;54:1698e705. 5. Chang DC, Rotellini-Coltvet LA, Mukherjee D, et al. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg 2009;49:630e5. 6. Urschel HC Jr, Kourlis H Jr. Thoracic outlet syndrome: a 50year experience at Baylor University Medical Center. Proc Bayl Univ Med Cent 2007;20:125e35.
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