Surgical Management of Vascular Thoracic Outlet Syndrome: A Teaching Hospital Experience

Abstract

The use of advanced radiological imaging and careful surgical planning for Vascular TOS in a high volume center resulted in good outcomes.

First rib removal and decompression of the thoracic outlet as an indication to facilitate hemodialysis

“…This approach has been previously reported to have good results, with symptomatic improvement in 85% in a series of 142 patients 4 and 100% in a series of 54 cases. 7 In patients undergoing AVF formation for dialysis access, venous hypertension is a well-known complication, occurring in 15% of cases. 8 In this scenario, the most common cause of venous hypertension is central venous stenosis secondary to endothelial trauma caused by an indwelling intravascular catheter.…”

Arterial Thromboembolism Secondary to Thoracic Outlet Syndrome

“…In a study by Aljabri, et. al, 100% of cases of arterial TOS were successful in providing complete relief of vascular symptoms after undergoing thoracic outlet decompression, including resection of cervical and/or first ribs [13]. In this case presentation, duplex ultrasound could have been performed intraoperatively at the conclusion of the patient's thoracic surgery intervention in order to immediately repair any residual vascular deficits.…”

The thoracic outlet syndromes: Part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes

“…Like TN‐TOS, it is almost always unilateral and more commonly involves young adults . Responsible etiologies include a large bony anomaly, a deformed first thoracic rib (FTR), another osseous process, anterior or middle scalene muscle hypertrophy, or intramuscular fibrous bands . Of these, a fully formed cervical rib is the most common cause .…”

“…The clinical features of A‐TOS, which were initially published by Sir Astley Cooper in 1821, are divided into vascular and neurologic . Subclavian artery compression leads to features of chronic upper extremity ischemia, including pain with effort, easy fatigability, claudication, extremity coolness, pallor, decreased capillary refill, an audible bruit, and diminution or absence of distal pulsations . Pulse diminution may not be recognizable unless the extremity is elevated into a position that compresses the artery .…”

“…In addition, cervical rib–induced subclavian artery damage may generate emboli that enter the vertebral or carotid artery circulation, causing ischemic brain infarction . With more severe ischemia, hand pain occurs at rest . Tissue necrosis from unrecognized ischemia may necessitate amputation.…”