Multicenter Case Series and Literature Review on Durability of Stents in the Thoracic Outlet

Abstract

Purpose: The aim of this paper was to report our experience with arterial and venous endovascular stent placement in the thoracic outlet (TO) and review available literature. Methods: All patients that underwent arterial or venous stent placement in the TO between 2013 and 2020 in 5 Dutch vascular teaching-hospitals were retrospectively identified. Primary endpoint was symptomatic stent failure due to stenosis, chronic or posture dependent compression, fracture, or occlusion of the stent. Secondary endpoints were symptoms at last follow-up and re-interventions. For the literature review, we searched studies reporting on stenting in the TO. Results: Twenty-six patients were included with 11 arterial and 15 venous stents implanted to treat angioplasty resistant stenosis in arterial or venous TO syndrome, iatrogenic or traumatic vascular injury, radiotherapy fibrosis, or arterial dissection. Median follow-up was 19 and 14 months in the arterial and venous-group, respectively. Eight (73%) patients in the arterial, and 9 (60%) in the venous-group suffered symptomatic stent failure. Seven (64%) patients in the arterial, and 9 (60%) in the venous-group required at least 1 re-intervention. When comparing all patients with stent placement after TO decompression (TOD) to patients without, there were substantially more symptomatic stent failures and re-interventions required in the patients without TOD. Six patients (54%) in the arterial-group and 11 (73%) in the venous-group were symptom-free at last follow-up. Five articles describing 51 patients with arterial and 6 articles describing 81 patients with venous stents were included in the literature review. In the arterial-group, no TOD prior to stent placement was performed, while in the venous-group all but 1 article performed TOD prior to stent placement. Results showed comparable rates of symptomatic stent failure (24% vs 30%), and patients requiring re-interventions (29% vs 21%) between groups. Conclusion: Based on our multicenter series and review, stents in the TO have a considerable risk of failure, both in the venous and the arterial territory. Especially in patients without TOD: the need for re-interventions is high and half the patients eventually undergo TOD. Based on the currently available data, stenting in the TO should be applied cautiously while TOD should be considered.

Current treatment strategies for primary upper extremity deep venous thrombosis; a retrospective observational multicenter case series

“…A total of five patients with VTOS received primary stent placement ( N = 2) or postoperative stent placement ( N = 3) with mixed results. This was in line with our recently published case series and literature review, where we found that both venous and arterial stents in the thoracic outlet have a considerable risk of failure, especially in patients who were stented without prior TOD ( 4 ). Moreover, due to a limited amount of evidence and reported mixed results, stent placement in the thoracic outlet is discouraged in the most recent ESVS guideline ( 22 ).…”

“…Invasive treatment consists of thoracic outlet decompression surgery (TOD), and in the presence of acute thrombosis it can be preceded by catheter directed thrombolysis (CDT). Additional percutaneous transluminal angioplasty (PTA) and/or venous stenting might be used in selected cases ( 4 ).…”

Functional outcome of arterial thoracic outlet syndrome treatment

“…All seven recurrent occlusions that occurred during follow-up, transpired in patients who were put on antiplatelet therapy, while none occurred in the patients using vitamin K antagonists or DOACs which might suggest that antiplatelet therapy is an inadequate therapy for postoperative ATOS patients. However, three out of seven re-occlusions occurred in patients with subclavian artery stents known for an increased risk of recurrent TE events and therefore an important confounder (by indication) in this study ( 15 ). Based on our series and currently available evidence an optimal postoperative antithrombotic treatment strategy for prevention of recurrent arterial occlusions in ATOS patients is still lacking.…”

The Use of Viatorr Stent at the Thoracic Outlet to Maintain Hemodialysis Access Function

“…Stent placement within the subclavian arteries and veins has been shown to have poor durability, likely due to mechanical motion within this region causing repetitive stress and structural failure of the stent. 2 Generally, stent placement in the subclavian vessels is not recommended. 3 This is particularly problematic in dialysis patients who rely on patent outflow veins for their dialysis access and are often not good surgical candidates for definitive decompressive surgery.…”