Thoracic Outlet Decompression Research Articles

Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget-Schroetter Syndrome

Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome [PSS]) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT), followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer on the basis of response. The aim of this study was to evaluate outcomes of this flexible protocol. Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. End points included success of TL and eventual clinical outcome. Patients were divided into two groups: group I, TL/PMT + TOD; and group II, medical management/anticoagulation + TOD. PSS was diagnosed in 103 patients; 97 (42 male, 55 female; mean age, 31 years) who underwent TOD were included in the study. Group I included 53 patients who underwent TOD after initial TL/PMT (30 at our institution and 23 elsewhere), with success (acute thrombus resolution) in 93% (n = 28) and 69% (n = 16), respectively. Adjunctive balloon catheter venoplasty was performed in 66%. TL failed to recanalize the occluded SCV in 16% (n = 9). Complete thrombus resolution was seen in 7% (n = 4). Residual chronic thrombus in 61% (n = 33) resulted in median SCV stenosis of 50% (range, 10%-80%). With continued anticoagulation, further thrombus retraction was noted with mean 30% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range, 2-240 days). Rethrombosis of the SCV occurred in three patients 1 to 3 days postoperatively and was managed with mechanical thrombectomy, SCV stenting, balloon angioplasty, and anticoagulation. Symptomatic relief was achieved in 46 of 53 (85%) patients at a median follow-up of 14 months. Group II included 44 patients who underwent TOD after medical treatment elsewhere with anticoagulation alone for an average of 6 months (range, 2-18 months), with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (88%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in seven patients (16%); the indication for TOD was residual symptoms from compression of collateral veins. In the remaining 37 patients, mean residual stenosis of 56% (range, 30%-80%) was noted in the SCV. TOD was performed at a median of 257 days after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in three patients and stenting in two. Symptomatic relief was achieved in 39 of 44 (88%) at a median follow-up of 24 months. For PSS, a management protocol encompassing elective TOD at a convenient time after TL is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the SCV and may reduce the need for open venous reconstruction.

Recurrent Upper Extremity Thrombosis Associated with Overactivity: A Case of Delayed Diagnosis of Paget-Schroetter Syndrome

Paget-Schroetter syndrome is thrombosis of the axillary-subclavian vein that is associated with strenuous and repetitive activity of the upper extremities. Overuse of the arm coupled with external compression results in microtrauma in the intima of the subclavian vein, resulting in the activation of the coagulation cascade. Diagnosis is usually made by Doppler ultrasound and the treatment involves thrombolysis, while routine surgical decompression of the thoracic outlet is controversial. In this report, we present a case of a patient who presented with a second episode of spontaneous right upper extremity deep venous thrombosis. The first episode was inadequately treated with oral anticoagulation alone. During the second episode, Paget-Schroetter syndrome was diagnosed, after careful review of his occupational history. He subsequently underwent angioplasty and decompression of thoracic outlet with no recurrence of thrombosis in a 12-month follow-up period.

A Fourteen-Year Experience with Vascular Anomalies Encountered during Transaxillary Rib Resection for Thoracic Outlet Syndrome

Transaxillary approach to first rib resection and scalenectomy (TAFRRS) is a well-established technique for treatment of thoracic outlet syndrome (TOS). Although anatomic features encountered during TAFRRS are in general constant, vascular anomalies may be encountered but have not been described to date. Herein we describe vascular abnormalities encountered during TAFRRS. We performed a retrospective review of a prospective practice database of 224 operations for TOS performed in 172 patients from March 2000 to March 2014. We excluded 10 patients with missing operative reports, 3 reoperations on the same patient, and 8 non-transaxillary resections. We recorded vascular anomalies identified in operative reports and reviewed computed tomography imaging to delineate the nature of these abnormalities. The overall incidence of vascular anomalies was 11% (22 of 203 TAFRRS). Most patients with anomalies had venous TOS (vTOS) (9 patients, 41%), followed by 7 (32%) with neurogenic TOS (nTOS). The remainder of the patients had arterial TOS (aTOS) (6 patients, 27%). Seven patients (32%) had an abnormal subclavian artery (SCA) with 5 (23%) having an abnormal arterial course in the anterior scalene muscle (ASM); 6 patients (27%) had an abnormal internal mammary artery (IMA) originating from distal SCA; 4 (18%) had abnormalities in the supreme thoracic artery (bifurcation or duplication); 2 (9%) had an abnormal branch from the SCA with anomalous location in the operative field; and 3 (14%) had an abnormal large venous branch penetrating the ASM. In the 19 patients with arterial anomalies, 8 (42%) were recognized as arterial branches penetrating the ASM, and 11 (58%) were noticed as they had anomalous arterial locations within the operative field. Most arterial anomalies were seen in vTOS (9, 45%), followed by nTOS (7, 35%). No intraoperative vascular complications occurred. Perioperative complications included 1 occurrence of postoperative transfusion for bleeding following axillary drain discontinuation and 2 Horner's syndromes. One aberrant IMA was electively ligated to allow complete thoracic outlet decompression. Arterial anomalies during TAFRRS are encountered in 11% of operations, and may present with vessel locations in unusual areas within the operative field, or as abnormal vessels penetrating the ASM, thus making scalenectomy precarious. Careful attention must be paid to possible abnormal locations of vessels in the thoracic outlet to avoid bleeding complications.

Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a condition caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. The incidence of TOS is reported as 0.3 to 2% in the general population. There are three distinct types of TOS: neurogenic (95%), venous (4%), and arterial (1%). Treatment algorithms depend on the type of TOS. Arterial and venous TOS often present urgently with arterial or venous thrombosis, which is fairly easily identified by thorough history taking and a physical examination. Diagnosis is also aided by duplex ultrasonography. Restoration of arterial or venous flow can often be readily accomplished by thrombolysis. More important, however, is the diagnosis of the underlying structural component involved in the development of symptoms. Although statistically the most common, neurogenic TOS is often the most difficult to diagnose and treat. There are good data indicating that appropriately selected patients benefit from surgical therapy for neurogenic TOS as well. To prevent recurrence of symptoms, patients must undergo first rib resection and anterior scalenectomy, as well as resection of any rudimentary or cervical ribs. Regardless of the type of TOS encountered, proper therapy requires a thorough diagnostic evaluation and multimodal treatment. Keywords: thoracic outlet syndrome, arterial thoracic outlet syndrome, neurogenic thoracic outlet syndrome, venous thoracic outlet syndrome, TOS, effort thrombosis, thoracic outlet decompression

Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (VTOS) is uncommon but most frequently occurs in young, active, healthy patients. This condition typically presents as subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome. Thepathophysiology underlying VTOS is chronic repetitive compression injury of the SCV in the costoclavicular space, resulting in progressive venous scarring, focal stenosis, and eventual thrombosis. Clinical evaluation includes a history and physical examination followed by catheter-based venography, for definitive confirmation of the diagnosis and initial treatment with pharmacomechanical thrombolysis. After restoration of SCV patency, patients are maintained with anticoagulation and surgical therapy is usually planned within 4 to 6weeks. Surgical management of VTOS can be accomplished via different protocols involving either the transaxillary, infraclavicular or paraclavicular approaches to thoracic outlet decompression. The paraclavicular approach is emphasized in this review, because it affords the surgeon the ability to safely perform complete thoracic outlet decompression (complete anterior and middle scalenectomy, removal of the entire first rib, and resection of the subclavius muscle and costoclavicular ligament), along with definitive management of the damaged SCV (external venolysis, intraoperative venography, and direct vein reconstruction, ifneeded, using patch angioplasty or bypass grafting), in one operative setting. After surgical therapy, interval anticoagulation and a comprehensive physical therapy and rehabilitation program are important in achieving a return to full function. Current protocols on the basis of the paraclavicular surgical approach have thereby routinely provided patients with lasting symptomatic relief, freedom from indefinite anticoagulation, and the ability to return tounrestricted upper extremity activity.

Performance Metrics in Professional Baseball Pitchers before and after Surgical Treatment for Neurogenic Thoracic Outlet Syndrome

High-performance throwing athletes may be susceptible to the development of neurogenic thoracic outlet syndrome (NTOS). This condition can be career-threatening but the outcomes of treatment for NTOS in elite athletes have not been well characterized. The purpose of this study was to utilize objective performance metrics to evaluate the impact of surgical treatment for NTOS in Major League Baseball (MLB) pitchers. Thirteen established MLB pitchers underwent operations for NTOS between July 2001 and July 2014. For those returning to MLB, traditional and advanced (PitchF/x) MLB performance metrics were acquired from public databases for various time-period scenarios before and after surgery, with comparisons made using paired t-tests, Wilcoxon matched-pair signed-rank tests, and Kruskal-Wallis analysis of variance. Ten of 13 pitchers (77%) achieved a sustained return to MLB, with a mean age of 30.2±1.4years at the time of surgery and 10.8±1.5months of postoperative rehabilitation before the return to MLB. Pre- and postoperative career data revealed no significant differences for 15 traditional pitching metrics, including earned run average (ERA), fielding independent pitching, walks plus hits per inning pitched (WHIP), walks per 9 innings, and strikeouts to walk ratio (SO/BB). There were also no significant differences between the 3years before and the 3years after surgical treatment. Using PitchF/x data for 72 advanced metrics and 25 different time-period scenarios, the highest number of significant relationships (n=18) was observed for the 8 weeks before/12 weeks after scenario. In this analysis, 54 (75%) measures were unchanged (including ERA, WHIP, and SO/BB) and 14 (19%) were significantly improved, while only 4 (6%) were significantly decreased (including hard pitch maximal velocity 93.1±1.0 vs. 92.5±0.9 miles/hr, P=0.047). Six pitchers remained active in MLB during the study period, while the other 4 had retired due to factors or injuries unrelated to NTOS. Objective performance metrics demonstrate that pitchers returning to MLB after surgery for NTOS have had capabilities equivalent to or better than before treatment. Thoracic outlet decompression coupled with an ample period of postoperative rehabilitation can provide effective treatment for professional baseball pitchers with career-threatening NTOS.

Infraclavicular first rib resection for the treatment of acute venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (VTOS) is most commonly treated by transaxillary, supraclavicular, or paraclavicular approaches, based on surgeon preference. However, we have adopted an infraclavicular approach to VTOS as the surgical pathology is in the anterior costoclavicular space. We hypothesize that this approach, combined with catheter-directed thrombolysis (CDT) with venoplasty as needed, provides safe and effective treatment of patients with an acute presentation of VTOS. We retrospectively reviewed all consecutive patients that underwent infraclavicular thoracic outlet decompression for an acute presentation of VTOS from July 2005 to February 2014 by a single surgeon. Acute presentation was defined as less than 14 days between the onset of symptoms and CDT. Demographics, primary and secondary subclavian vein patency, perioperative outcomes, and reinterventions were recorded. There were 33 patients that underwent an infraclavicular approach for treatment of VTOS. Average age was 35 years, and 61% were male. All patients underwent CDT, subsequent infraclavicular first rib resection, and intraoperative venography. Intraoperative subclavian vein angioplasty was performed in 70%. Median postoperative length of stay was 2 days (range, 2-6 days), blood loss was 78 mL (range, 20-200 mL), and operative time was 120 minutes (range, 76-166 minutes). Median follow-up was 78 days (range, 2-483 days). Follow-up ultrasound showed all patients having a patent subclavian vein at last follow-up. Reinterventions included two cases for rethrombosis and one case of hemothorax. Primary patency was 91%, and secondary patency was 100%. There were no complications of brachial plexus or phrenic nerve injury. All patients at last follow-up were symptom-free, and subclavian veins were patent. An infraclavicular approach is a safe and effective treatment for acute VTOS. It provides excellent access to the costoclavicular space for first rib resection and subclavian venolysis while at the same time minimizing the risk of brachial plexus and phrenic nerve injury.

VS5. Operative Management of Venous Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) usually affects young, active, otherwise healthy individuals. TOS is classified as neurogenic (NTOS), venous (VTOS), or arterial (ATOS). VTOS arises from repetitive compression injury to the subclavian vein (SCV) in the costoclavicular space, resulting in chronic fibrosis, stenosis, collateral vein expansion, and eventual thrombosis. The signs and symptoms associated with SCV thrombosis include spontaneous arm swelling, cyanosis, distension of collateral veins, exertional heaviness and fatigue, and pulmonary embolism. The clinical diagnosis of VTOS is supplemented by imaging studies (MRV, CTV or venography). Patients presenting with SCV thrombosis undergo pharmacomechanical thrombolysis, followed by positional venography to confirm the extent and location of residual SCV compression. Interval anticoagulation is used prior to thoracic outlet decompression. The most frequently used surgical techniques are transaxillary first rib resection (with follow-up venography and angioplasty) and paraclavicular decompression with/without direct SCV reconstruction (patch angioplasty or bypass). The patient is positioned supine on a fluoroscopy-compatible table with the affected arm prepared. A supraclavicular incision is made, subplatysmal flaps are raised, and the scalene fat pad is retracted laterally after identifying the phrenic nerve. The anterior and middle scalene muscles are completely resected. The posterior first rib is divided with the brachial plexus well protected. An infraclavicular incision is then carried through the pectoralis major muscle, and the medial first rib is divided at the level of the sternum. The subclavius muscle is fully resected and external venolysis is completed through both incisions, followed by completion venography. If residual subclavian vein obstruction exists, the patient undergoes direct subclavian vein reconstruction using either patch angioplasty or bypass.

Acute Paget–Schroetter Syndrome: Does the First Rib Routinely Need to Be Removed after Thrombolysis?

Most clinicians feel that treatment for patients with acute primary axillosubclavian vein thrombosis ("effort thrombosis") is catheter-directed thrombolysis followed by thoracic outlet decompression. Several investigators feel that first rib resection (FRR) is not indicated in every case. No randomized data exist to answer this question. A MEDLINE search was done using the terms "Paget-Schroetter syndrome," "upper extremity DVT," "first rib resection," "effort thrombosis," and "primary upper extremity thrombosis," with thrombolysis used as an "AND" term. We also specifically explored references cited to support either side of this argument in the past. Analysis was limited to patients aged 18years or older with symptoms of 14-day duration or less undergoing thrombolysis for primary axillosubclavian vein thrombosis. Those studies that did not report follow-up, duplicate series from the same institution, and those in which patients were stented were excluded. Results were analyzed on an intent-to-treat basis, with groups assigned according to each authors' prospectively described algorithm. Twelve series were included. Patients were divided into 3 groups according to treatment after thrombolysis: FRR (448 patients), FRR plus endovenous balloon venoplasty (FRR+PLASTY; 68 patients), and those with no further intervention after thrombolysis (rib not removed; 168 patients). Symptom relief at last follow-up was significantly more likely in the FRR (95%) and FRR+PLASTY (93%) groups than in the rib not removed (54%) group (both <0.0001) as was patency (98%, 86%, and 48%, respectively; both <0.0001 vs. rib not removed). More than 40% of patients in the rib not removed group eventually required rib resection for recurrent symptoms. No differences in symptom-free rates were seen when comparing FRR with FRR+PLASTY. In patients with acute effort thrombosis who undergo thrombolysis, permanent symptom relief and long-term patency are more likely to be achieved in patients who undergo FRR with or without endovenous balloon venoplasty than those whose rib is left intact.

Arm Pain and Discoloration in a 15yo Swimmer

HISTORY: A 15yo swimmer presented with intermittent right shoulder pain, swelling, and purple discoloration. 8 months prior to presentation, the pt was swimming and noticed a gradual onset of right shoulder pain. When she got out of the pool, she noticed slight right arm swelling and purple discoloration from her shoulder down. It took approximately 2 days for her symptoms to completely resolve. She took 1w off swimming and then returned. The next swim again resulted in right arm pain, swelling, and purple discoloration. The pt stopped swimming at that time. Over the next 6 months, she notes intermittent similar but less severe symptoms with most physical activity including softball and basketball. She reports occasional symptoms with no specific activity, and cannot identify a common motion or arm position that brings the symptoms on. Between episodes, she denies any arm swelling, shoulder pain, or discoloration. She is otherwise healthy, and denies left arm symptoms, preceding injury, chest pain, SOB, or persistent swelling of the right arm. PHYSICAL EXAM: Exam reveals a well appearing young female in no acute distress. Shoulders appear symmetric. She has tenderness over the anterior shoulder and AC joint. She has full active and passive ROM of the shoulder. No tests for impingement, RTC syndrome, labral pathology, or instability produce symptoms. Active flexion of shoulder to 165 degrees for 5 minutes did not produce symptoms. During US of the shoulder, with the pts arm at her side and slightly externally rotated, she developed mild mottling of the arm, slight swelling, and pain. She had 2+ radial pulses and no sensory deficits. DDx: Venous thoracic outlet syndrome Neurogenic thoracic outlet syndrome Rotator cuff syndrome Cervical radiculopathy Brachial plexus injury TESTS AND RESULTS: MR Arthrogram: No pathologic findings. RUE Venography: Occlusion of the right subclavian vein with abduction of the right shoulder. Patent subclavian vein in neutral position FINAL WORKING DIAGNOSIS: McCleery’s Syndrome (intermittent subclavian vein occlusion without thrombosis) TREATMENT AND OUTCOMES: Pt is scheduled to undergo surgical thoracic outlet decompression

Paget-Schroetter Syndrome in 21 Children: Outcomes after Multidisciplinary Care

To review the presentation, management, and outcomes of Paget-Schroetter syndrome (PSS) in children and propose a multidisciplinary treatment algorithm involving pediatric and vascular surgery, interventional radiology, and hematology. Patients with PSS presenting between 2003 and 2013 were reviewed. Demographics, symptoms, therapies, and functional outcomes were noted. Data from early patients informed the development of a multidisciplinary treatment algorithm applied to later patients. Of 21 patients, mean ± SD age was 16 ± 1.6 years and 11 (52%) were male. Of patients with complete presentation data, common symptoms were edema (84%), discoloration (58%), and pain (58%). Thrombophilia workup revealed one heterozygote for factor V Leiden, 2 patients with factor VIII elevation and 1 patient with mildly low antithrombin. The most recent 8 patients were treated according to an algorithm developed by a multidisciplinary working group through experience with the first 13 cases. All patients underwent a venogram, endovascular intervention (including 15 receiving catheter-directed thrombolysis), and operative ipsilateral thoracic outlet decompression (first rib resection, anterior scalenectomy, and venolysis). Postoperative complications included hemothorax (2), pneumothorax (1), and recurrent thrombosis (2). Follow up duration was 12 ± 9.5 months. Symptoms recurred transiently in 1 patient. Pediatric patients with PSS can be treated successfully using a multidisciplinary treatment algorithm including anticoagulation, catheter-directed thrombolysis, and operative decompression of the thoracic outlet. Early outcomes are promising.

Outcome of trans-axillary approach for surgical decompression of thoracic outlet: a retrospective study in a tertiary care hospital.

The aim of this study was to evaluate the trans-axillary surgical approach in patients with thoracic outlet syndrome. This retrospective study is comprised of data acquired from January 1998 until Oct 2008. Case histories of all the patients were reviewed from the Medical Records Department of Sher-i-Kashmir Institute. Relevant information and follow-up of the patients was carried out by examining the relevant clinical notes available by telephone interviews and personal contact whenever possible. All data was compiled and analyzed statistically. There were a total of 139 patients. The female: male ratio was about 6:1. Pain was the most common presenting symptom followed by weakness and parasthesia. Nerve conduction velocity was abnormal in 111 patients. Twenty-eight patients had abnormal Doppler study of subclavian vessels. Preoperative symptoms persisted in 13 patients. Overall, 126 patients showed improvement in symptoms and no recurrence or persistence of symptoms on follow-up examination. Trans-axillary approach provides a good exposure and cosmesis in patients with thoracic outlet syndrome. It should be considered as the gold standard in the management of thoracic outlet syndrome.

Outcomes of Surgical Paraclavicular Thoracic Outlet Decompression

Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery, resulting in neurogenic (NTOS), venous (VTOS), and arterial (ATOS) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of paraclavicular surgical decompression for TOS. A prospective analysis of patients who underwent surgical decompression for TOS at a newly established center was performed. Diagnosis of TOS was based on clinical history, a physical examination, and additional diagnostic studies. The indication for surgery in patients diagnosed with NTOS was the presence of persistent symptoms after a trial of physical therapy. Primary outcomes were assessed according to Derkash's classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and duration of hospital stay. Between August 2004 and June 2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 men) with TOS. The mean age was 36.5 years (range: 15-68). Bilateral decompression was performed on 4 patients. The types were NTOS (n = 19; 48%), VTOS (n = 16; 40%), and ATOS (n = 5; 12%). In addition to pain, the most common presenting symptom was numbness in NTOS, swelling in VTOS, and coolness in ATOS. A history of trauma was present in 22.2%. Two patients suffered from recurrent symptoms after previous transaxillary first rib resection for VTOS at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and first rib resection. The first rib resection was partial, through a supraclavicular only approach in NTOS and ATOS patients (60%) or complete, through a supra- and infraclavicular approach for VTOS patients (40%). Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow-up. Two patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths. Complications included pleural effusion requiring evacuation (n = 4), neuropraxia (n = 1), and lymph leak (n = 1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean duration of hospital stay was 4.4 days. The mean follow-up was 10.3 months. In our experience, surgical paraclavicular decompression can provide safe and effective relief of NTOS, VTOS, and ATOS symptoms. Functional outcomes were excellent or good in the majority of patients, with minimal complications.

Long-term clinical and functional outcome following treatment for Paget–Schroetter syndrome

Effort-related thrombosis of the axillosubclavian vein (Paget-Schroetter syndrome, PSS) is uncommon. It tends to affect young, active individuals and yet consensus on management is lacking. The aim here was to analyse late outcomes in a series of patients treated for PSS using a standard protocol. The medical records of patients treated for PSS over 16 years were analysed. Patients were divided into four groups according to their management. Clinical and functional outcomes were analysed regarding residual venous defects after treatment, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, respectively. Some 117 patients (52 men and 65 women, mean age 32 years) were included. Catheter-directed thrombolysis was successful in 42 of 56 treated patients. Thoracic outlet decompression surgery was performed in 95 patients. DASH scores improved significantly in patients treated surgically (P < 0.001 to P = 0·009); early surgery had a better outcome than delayed surgery (P = 0·040). Patients who were managed conservatively showed no improvement (P = 0·116). Where venoplasty was necessary, it was successful in 18 of 25 patients. A short duration of lysis (less than 24 h) increased the risk of rethrombosis (P = 0·020). The method of postoperative anticoagulation had no influence on the rate of rethrombosis. Patients treated surgically for PSS had better functional outcomes than those managed conservatively. Prompt thrombolysis and surgery was superior to delayed management with respect to rethrombosis and functional outcome.

Contemporary management of axillosubclavian vein thrombosis

Axillosubclavian vein thrombosis, also referred to as effort thrombosis or Paget–Schroetter syndrome, is the most common presentation of the venous form of thoracic outlet syndrome. With timely diagnostic and therapeutic measures, thrombosis of the axillary or subclavian veins can be treated with minimal long-term morbidity. Case reports and single-center reviews have greatly contributed to our understanding of the pathophysiology, clinical presentation and most effective treatment modalities for venous thoracic outlet syndrome. This article provides an evidence-based review of the contemporary management of venous thoracic outlet syndrome, emphasizing the role of diagnostic venography, catheter-directed thrombolysis and prompt thoracic outlet decompression. In addition, controversies in current therapy and perspectives on future research will be addressed.

Neurogenic Thoracic Outlet and Pectoralis Minor Syndromes in Children

Brachial plexus compression (BPC) occurs above the clavicle as neurogenic thoracic outlet syndrome (NTOS) and below as neurogenic pectoralis minor syndrome (NPMS). It was recently noted that 75% of the adults seen for NTOS also had NPMS and in some this was the only diagnosis. This is also true in children but has not yet been reported. Because surgical treatment of NPMS is a minimum risk operation for pectoralis minor tenotomy (PMT), recognition of NPMS and distinguishing it from NTOS becomes important. In this study, 40 operations, 20 PMT and 20 NTOS procedures, were performed. Success rate for PMT was 85% and for thoracic outlet decompression was 70%. It was concluded that in children, as in adults, BPC is more often due to combined NTOS and NPMS. Surgical PMT should be considered first as the treatment of choice for children with NPMS. Thoracic outlet decompression is available if PMT is unsuccessful.

Modernizing the treatment of venous thoracic outlet syndrome

This study aims to quantify the management and outcomes of patients treated for venous thoracic outlet syndrome (vTOS) over a seven-year period. A retrospective case-note review of all patients undergoing first rib resection at a regional vascular unit between January 1, 2002 and December 31, 2009 was performed. Treatment pathways and outcomes recorded as freedom from symptoms and venous patency were analyzed. Thirty-five patients were identified with vTOS. Ninety-one percent of patients had patent veins at discharge from clinical follow-up and were symptom-free at a median of 44 months. Patients treated within seven days of symptoms (94.7 versus 85.7, P = 0.060), with catheter-directed thrombolysis (94 versus 87.5% P = 0.702) and excision of first rib in less than 30 days (100 versus 85.7%, P = 0.002), had improved symptom-free rates. In conclusion, early referral, immediate catheter-directed thrombolysis, perioperative balloon venoplasty and early thoracic outlet decompression may provide a suitable model for improving outcomes in vTOS.

Lung Herniation After Supraclavicular Thoracic Outlet Decompression

Lung herniation after first rib resection for thoracic outlet syndrome (TOS) has not been reported to our knowledge. We present a unique case of cervical lung herniation causing displacement of the brachial plexus and chronic pain in a patient who had previously undergone supraclavicular thoracic outlet decompression with first rib resection. This was successfully treated with thoracoscopic reduction and resection of the herniated lung and pleural flap closure of the defect.

Comprehensive Management of Subclavian Vein Effort Thrombosis

Subclavian vein (SCV) effort thrombosis, also known as the Paget-Schroetter syndrome, is a relatively uncommon condition that affects young, active, otherwise healthy individuals. It is considered a form of thoracic outlet syndrome, arising as a consequence of compression and repetitive injury of the SCV between the first rib and the overlying clavicle, as well as the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. Effort thrombosis is distinct from other forms of deep vein thrombosis with respect to pathophysiology, clinical presentation, and functional consequences, and it requires treatment considerations unique to effective management of thoracic outlet compression as well as the obstructed SCV. In this review the comprehensive management of SCV effort thrombosis is addressed, with an emphasis on current interventional radiology techniques used in conjunction with definitive surgical treatment, based on early catheter-based venography, thrombolytic therapy, and prompt paraclavicular thoracic outlet decompression with direct SCV reconstruction.

Costochondral calcification, osteophytic degeneration, and occult first rib fractures in patients with venous thoracic outlet syndrome

Subclavian vein (SCV) compression in venous thoracic outlet syndrome (TOS) has been attributed to various anatomic factors, but a potential role for costochondral degeneration in the underlying first rib has not been previously examined. The purpose of this study was to examine the frequency of costochondral calcification (CC), osteophytic degeneration (OD), and occult first rib fractures (FRFx) in patients with venous TOS. Thirty-seven patients (21 male, 16 female) were referred for surgical treatment of venous TOS during a 12-month period, with a mean age of 30.7 ± 1.8 year (range, 12-55). Thirteen (35%) had acute SCV effort thrombosis and 24 (65%) had chronic symptoms (>14 days). Twenty (54%) had undergone SCV thrombolysis, 11 (30%) had persistent SCV occlusion, and 10 (27%) had concomitant symptoms of neurogenic TOS. All patients underwent paraclavicular thoracic outlet decompression with complete resection of the first rib to the sternum, with 20 (54%) having concomitant SCV reconstruction. The presence or absence of CC, OD, and FRFx was determined by direct visual examination of the rib at operation and following debridement of the excised specimen. One patient had a cervical rib but there were none with radiographic first rib abnormalities. In contrast, FRFx were observed at surgical resection in 16 of 37 patients (43%). All FRFx were small, nondisplaced, linear lesions located within an area of CC in the anterior rib, typically in association with OD and perivenous soft tissue thickening. The mean age of patients with FRFx was higher than those with a normal first rib (38.1 ± 1.5 years vs 25.0 ± 2.3 years; P < .0001), and FRFx were present in 16 of 21 (76%) patients ≥ 30 years of age but in no patients younger than 30 (P < .0001). A high proportion (43%) of patients with venous TOS exhibited CC, OD, and a previously undetected FRFx, including 76% of those over the age of 30. These lesions occur in the cartilaginous anterior rib where they are clinically occult and undetected by standard radiographic imaging. We postulate that age-related CC may predispose to OD and stress-induced FRFx, and that inflammation, fibrosis, and anatomic distortion in the surrounding soft tissues may contribute to SCV compression.