Should Thoracic Outlet Syndrome Patients Ever Undergo Bilateral First Rib Resection and Scalenectomy?

Abstract

Due to the small numbers of thoracic outlet syndrome (TOS) patients treated with bilateral first rib resection and scalenectomy (FRRS), this patient subset has not been well studied. We examined a large cohort of TOS patients who underwent bilateral FRRS to evaluate patient characteristics and outcomes. Patients treated with bilateral FRRS at Johns Hopkins Medical Institutions from 2003-2012 were identified by review of a prospectively maintained database. Statistical analysis compared patients with unilateral and bilateral FRRS, and bilateral patients with different TOS indications. 53 patients underwent bilateral FRRS with a mean follow-up of 11.4 months. Average time between operations was 17.0 (range, 5.1-59.8) months. Compared to 408 unilateral FRRS patients, bilateral patients were younger (30 vs 35 years; P < .008) with no significant difference in gender. Among patients with dual-sided FRRS, 25 (47%) had bilateral neurogenic (N) symptoms, two (4%) had bilateral arterial symptoms, and 26 (49%) had venous symptoms with the first side due to intermittent compression (IC) in five (second side 4 IC, 1 N) and effort thrombosis (ET) in 21 (second side 9 ET, 8 IC, 4 N). 12 patients had prophylactic FRRS to prevent contralateral venous or arterial thrombosis, and eight had cervical ribs. Compared to neurogenic patients, venous patients were younger (25 vs 35 years; P < .002) with a trend towards more competitive athletes (7 venous vs 2 N). Symptomatic restenosis requiring dilation occurred after four FRRS for venous symptoms at a mean of 32 months, and rethrombosis occurred after four FRRS at a mean of 4 weeks (1 treated with warfarin, 3 with tPA), all on the primary side. Overall, 89% of FRRS led to resolved symptoms at last follow-up. Bilateral FRRS is an effective method for symptomatic and prophylactic treatment of TOS. Venous bilateral patients are more often younger, competitive athletes, and must be monitored closely postoperatively for recurrent stenosis and thrombosis.