Performance of First Rib Resection by Vascular Surgeons for Thoracic Outlet Syndrome Minimizes Hemorrhagic Complications

Abstract

Thoracic outlet syndrome (TOS) takes on heterogeneous upper extremity manifestations depending on whether the artery, vein, or brachial plexus is primarily compressed. Despite sharing a common mechanism, the operative and perioperative management of these distinct types of TOS is disparate. As a result of these variable vascular and neurogenic symptoms, patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work, we examine the impact of surgeon specialty on short-term outcomes of first rib resection (FRR) for TOS. Using the American College of Surgeons National Surgical Quality Improvement Program database, 3070 patients were identified who underwent FRR for TOS during 2006 to 2017. Arterial, venous, and neurogenic TOS types were distinguished with International Classification of Diseases, Ninth Revision and Tenth Revision codes; patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and International Classification of Diseases data. Data analysis was performed with Stata version 14.2 (StataCorp LP, College Station, Tex). Most FRRs were performed by vascular surgeons (87.9%), general surgeons (6.9%), and thoracic surgeons (4.4%). The practice patterns between the specialties were significantly different (P < .001), with non-vascular surgeons operating on a significantly more undifferentiated TOS than vascular surgeons (16.9% vs 4.4%) but not less arterial or venous TOS (1.1% vs 2.4% and 8.6% vs 9.1%, respectively). Patients who underwent FRR with non-vascular surgeons experienced more frequent rate of postoperative transfusion (3.2% vs 1.2%; P = .001) and wound infection (1.9% vs 0.8%; P = .04). On multivariate regression, patients receiving FRR for venous TOS were more likely to experience an episode of postoperative hemorrhage requiring transfusion (odds ratio, 3.63; 95% confidence interval [CI], 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRR had a 40% longer length operative time (incidence rate ratio, 1.42; 95% CI, 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratio, 9.87; 95% CI, 2.28-42.68). These results suggest that despite the fact that vascular surgeons have a TOS practice with equivalent increased vascular complexity compared with non-vascular surgeons, their postoperative hemorrhage rates are decreased. This is likely due to the independent association between venous TOS and postoperative hemorrhage and pertains to familiarity with perioperative anticoagulation management as well as operative factors. The significantly increased operative times and transfusion requirements independently associated with specialties that uncommonly perform FRR raise further questions about the role of surgeon experience and volume in this procedure.