IF13. Arterial Thoracic Outlet Syndrome: Outcomes of Direct Repair of Subclavian Artery Aneurysms

Abstract

Arterial complications of thoracic outlet syndrome (TOS) are rare (<1%). Surgery involves decompression of thoracic outlet, repair of subclavian aneurysm, and often embolectomy. Most published series have reported interposition graft for repair of subclavian aneurysm. The objective of this study was to evaluate the long-term results of decompression and direct repair of subclavian artery aneurysm in arterial TOS. This was a retrospective review of a prospectively maintained database. All patients who underwent surgery for arterial TOS from January 2001 to April 2017 were included. Patients’ demographics, presentation, treatment, and outcomes were reviewed. Direct repair of subclavian artery aneurysm included longitudinal arteriotomy, intimectomy, and tailoring. There were 62 operations performed on 53 patients for arterial TOS. Mean age at presentation was 35.62 years (range, 13-65 years). The female to male ratio was 1.65:1.0. There were 12 patients with bilateral arterial TOS, although all presented with unilateral symptoms. Three patients presented with acute limb ischemia. The remaining patients had delayed presentation (range, 30 days-2 years), including neck pain and swelling (7), upper limb claudication (33), rest pain and digital cyanosis (5), and stroke (1). The cause of arterial TOS was complete cervical rib in 50 (94%) patients (12 bilateral), incomplete first rib in 2 (4%) patients, and compression with scalenus anticus in 1 (2%) patient. All 12 asymptomatic TOS patients showed arterial compression, and 3 patients refused surgery for the asymptomatic limb. Surgery included thoracic outlet decompression by anterior scalenotomy (62), excision of cervical rib (59), and excision of first rib (3). Of the 62 operations (89%), 55 included direct repair of subclavian aneurysm: longitudinal arteriotomy, intimectomy, and aneurysmorrhaphy; 2, resection and end-to-end anastomosis; and 2, interposition grafts. Trans-subclavian embolectomy was done in 47 and transbrachial in 27 patients. Early complications included hemothorax requiring chest drain (one), lymph leak (one), phrenic nerve paresis (one), and brachial neurapraxia (two). Mean follow-up was 2 years (range, 6 months-5 years); 13 patients were lost to follow-up after 6 months. Follow-up is at regular intervals clinically and with duplex ultrasound scan. Residual ischemia (asymptomatic) is present in 12 of 53 patients (23%). One patient has persistent neuralgia. Asymptomatic dilation of directly repaired subclavian artery was identified in one patient at 18 months of follow-up, and he is under surveillance. Direct repair of subclavian artery aneurysm in arterial TOS patients can be performed safely. Recurrent dilation is rare and can be managed conservatively.