Supraclavicular Versus Transaxillary First Rib Resection for Thoracic Outlet Obstruction: A Single-Institution Experience

Abstract

Objectives: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures supplying the upper extremity as they exit through the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. The transaxillary (TA) approach has been the preferred approach, although the supraclavicular (SC) approach has become more widely used, especially when adjunct procedures are required. Our objective was to review the results with both approaches in our institution.Methods: A retrospective review of patients who underwent thoracic outlet decompression between 2009 and 2014 at the University of Iowa Hospitals and Clinics was conducted. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected preoperatively. Operative times, hospital length of stay, perioperative complications, and outcomes were also studied.Results: During the study period, 82 thoracic outlet decompression procedures were performed: 48% were for neurogenic TOS, 46% for venous TOS, and 6% for arterial TOS. Thirty-nine patients (47.5%) underwent the TA approach, and 43 (52.5%) underwent the SC approach. Adjunct procedures were performed in 16% of patients in addition to decompression, 85% of which were in the SC group. There was a significant difference in average operative time between TA and SC (124.5 vs 157 minutes; P < .05) but no differences in hospital length of stay. Minor complications were seen in 20% of patients, with no significant difference between the TA and SC groups. Major complications occurred in 6%, with four patients (3 TA and 1 SC) requiring re-exploration. There were no perioperative or 30-day deaths. On follow-up, 37% of patients with neurogenic TOS had complete resolution of symptoms, 54% had partial improvement, and 9% had no improvement. In both the venous and arterial TOS groups, 66% had complete symptom resolution and 34% had partial resolution. There was no difference in symptom resolution between the TA and SC groups.Conclusions: There is no significant difference between TA and SC approaches for TOS in perioperative complications, length of stay, and improvement of symptoms. Although operative time appears to be longer in the SC group, this can be attributed to adjunct procedures, including vascular reconstructions performed using this approach.

Arterial thoracic outlet syndrome

“…Surgical options include first rib with cervical rib resection either via transaxillary or supraclavicular approaches with possible aneurysm resection and bypass graft placement (12). There are no distinct advantages or disadvantages to either approach although there are studies suggesting that supraclavicular approaches are associated with longer operative times (13).…”

A cadaveric demonstration of the transaxillary approach to first rib resection for the treatment of thoracic outlet syndrome

“… 3 Several studies have shown no significant differences in outcomes between the transaxillary and supraclavicular approaches. 4 , 5 …”