Endovascular Stent-Graft and First Rib Resection for Thoracic Outlet Syndrome Complicated by an Aneurysm of the Subclavian Artery

Purpose: To report our experience with a combined endovascular and surgical approach for arterial thoracic outlet syndrome (TOS) complicated by an aneurysm of the subclavian artery.

Methods: We treated three consecutive patients suffering from arterial thoracic outlet syndrome complicated by an aneurysm of the subclavian artery by the use of a stent-graft and a first rib resection. These patients were reviewed retrospectively.

Results: At a mean follow-up of 37.3 months all patients were free of symptoms without late complications. Conclusions: Endovascular stent-grafting followed by decompression of the costoclavicular space is an attractive alternative to the conventional surgical approach of complicated arterial TOS.     

Supraclavicular Approach for Thoracic Outlet Syndrome

The authors' experience with the supraclavicular approach for the treatment of patients with primary thoracic outlet syndrome (TOS) and for patients with recurrent TOS or iatrogenic brachial plexus injury after prior transaxillary first rib resection is presented. The records of 33 patients (34 plexuses) with TOS who presented for evaluation and treatment were analyzed. Of these, 12 (35%) plexuses underwent surgical treatment, and 22 (65%) plexuses were managed non-operatively. The patients who were treated non-operatively and had an adequate follow-up (n = 11) were used as a control group. Of the 12 surgically treated patients, five patients underwent primary surgery; four patients had secondary surgery for recurrent TOS; and three patients had surgery for iatrogenic brachial plexus injury. All patients presented with severe pain, and most of them had neurologic symptoms. All nine (100%) patients who underwent primary surgery (n = 5) and secondary surgery for recurrent TOS (n = 4) demonstrated excellent or good results. On the other hand, six (54%) of the 11 patients from the control group had some benefit from the non-operative treatment. Reoperation in three patients with iatrogenic brachial plexus injury resulted in good result in one case and in fair results in two patients; however, all patients were pain-free. No complications were encountered. Supraclavicular exploration of the brachial plexus enables precise assessment of the contents of the thoracic inlet area. It allows for safe identification and release of all abnormal anatomical structures and complete first rib resection with minimal risk to neurovascular structures. Additionally, this approach allows for the appropriate nerve reconstruction in cases of prior transaxillary iatrogenic plexus injury.     

胸廓出口综合征的外科治疗

１９８０年至１９９３年间共收治胸廓出口综合征病人５５例，行经腋路切口胸出口松解术６２次，手术完全切断前，中斜角肌，切除带有骨膜的第一肋，松解锁骨下动脉和臂丛神经周围的纤维带，同时切除颈肋或过长的横突及其附着韧带，术后随访率为９６．４％，平均随访７．７年，结果良好８１．１％，改善１３．２％，无变化５．７％，无复发病例，作者认为经腋路切口胸出口松解术是治疗胸廓出口综合征较理想的术式。     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) consists of a group of distinct pathologies arising as a result of compression of structures at the thoracic outlet. The structures at risk are, from anterior to posterior, the subclavian vein, subclavian artery and brachial plexus. Compression or impingement causes venous (VTOS), arterial (ATOS) or neurogenic (NTOS) TOS. NTOS is the most common presentation, caused by compression of the brachial plexus at the scalene triangle or pectoralis minor space. Other compression syndromes at the carpal and cubital tunnels should be excluded. Management is usually conservative, employing physiotherapy and postural exercises, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction, resulting in venous thrombosis, the Paget-Schroetter syndrome, often as a result of exercise in fit young muscular people or musicians. Positional swelling of the upper limb without thrombosis is termed McCleery's syndrome. In the presence of thrombosis, clot lysis, first rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery at the scalene triangle, often in association with an anomalous bony structure, such as cervical rib, causing post-stenotic aneurysmal dilation of the artery, thrombosis and embolization. Acute upper limb ischaemia necessitates urgent cervical rib excision and arterial reconstruction.     

Thoracic outlet syndrome

Thoracic Outlet Syndromes (TOS) consists of a group of distinct pathologies arising from compression or impingement of structures at the thoracic outlet. The structures at risk are, from anterior to posterior, subclavian vein (venous — VTOS), subclavian artery (arterial — ATOS) and brachial plexus (neurogenic — NTOS). NTOS is the most common presentation, usually caused by compression of the brachial plexus at the scalene triangle or pectoralis minor space. Neurogenic compression syndromes at the carpal and cubital tunnels should be excluded. Management of NTOS is usually conservative, employing physiotherapy and postural exercises, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction, resulting in venous thrombosis (Paget—Schroetter syndrome) often as a result of exercise in fit young muscular people or musicians. Positional swelling of the upper limb without thrombosis is termed McCleery's syndrome. In acute thrombosis, clot lysis, first rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery at the scalene triangle, often in association with an anomalous bony structure, such as cervical rib, causing post-stenotic aneurysmal dilation of the artery, thrombosis and distal embolization. Acute upper limb ischaemia necessitates urgent cervical rib excision and arterial reconstruction.     

Thoracic outlet syndromes

Thoracic outlet syndrome (TOS) is no longer considered to be a single entity. The syndromes are venous (V-TOS), arterial (A-TOS) and neurological (N-TOS), but may co-exist. The end stage of VTOS (Paget Schroetter syndrome or effort thrombosis of the subclavian vein) should be recognized early so that younger sportsmen and musicians in particular can be offered the opportunity of thrombolysis, decompression surgery and balloon venoplasty. Most uncomplicated cases of A-TOS and N-TOS can be treated conservatively with posture, diet, physiotherapy advice and reassurance. Complicated arterial TOS, with aneurysm or embolization, should be treated expeditiously by cervical rib excision and arterial reconstruction. Double crush syndromes are relatively common in patients with TOS. It is easier to treat carpal tunnel syndrome than N-TOS. Muscle wasting and pain are an indication for surgery in N-TOS.     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) should no longer be considered a single entity. The syndromes are venous (V-TOS), arterial (A-TOS) and neurological (N-TOS), but may co-exist.     

Arterial complications of thoracic outlet syndrome

Objective: Arterial vascular complications resulting from thoracic outlet compression, although rare, can be substantial and potentially limb threatening. These complications are due to compressions at the thoracic outlet, the treatment of which continues to be a dilemma. The objective of the present study was to review our experience with this problem with particular reference to its management. Methods: We performed a retrospective study of 12 years and retrieved data from the medical records department of Nizam’s Institute of Medical Sciences, Hyderabad, India. A retrospective review identified 35 patients (age range 15–50 years). In 31 patients, the vasculopathy was caused by a cervical rib, soft tissue anomalies (n = 31), and an elongated transverse process (n = 4). Evaluation included assessment with colour duplex and arteriography with positional maneuvers. Thirty‐two patients presented with a fixed pulse deficit, 22 patients had palpable mass and 15 patients had distal embolization. Results: In 31 patients with cervical rib, the rib was excised via a supraclavicular approach, Scalenectomy was performed and the arterial pathology was repaired on its merit, usually by a vein graft replacement or bypass. The elongated process was excised in the other four patients. Twelve patients required thrombectomy of the distal arteries and a bypass procedure (with a vein/prosthetic graft) was performed in 14 patients. Dorsal sympathectomy, as an adjunct, was carried out in 10 patients. In view of their advanced distal disease, four patients were given prostaglandin therapy. Short‐term follow up of 2 years showed good results. Conclusion: Our results show that simple excision of the cervical rib with scalenectomy via supraclavicular approach, together with arterial reconstruction (if required) is adequate for arterial vascular complications resulting from thoracic outlet compression. Patients with severe distal disease may require other adjunct procedures like dorsal sympathectomy or prostaglandin infusions along with proximal reconstruction.     

胸廓出口综合征手术方法改良

目的 在解剖学研究和临床分析的基础上提出了胸廓出口综合征手术方法的改良。方法 ３０例尸体解剖,研究前、中、小斜角肌的起止点和臂丛神经的关系。随访了术后６个月￣２年的１９例颈肩痛和手部麻木,肌肉萎缩的胸廓出口综合征患者,均做前,中斜角肌起点和小斜角肌切断术。     

Collateral Artery Aneurysm: A Unique Presentation of Thoracic Outlet Syndrome

Aneurysms of collateral arteries are unusual. A case of transverse cervical artery aneurysm as the sole presentation of vascular thoracic outlet syndrome is presented and the relevant literature reviewed.