First Rib Resection Research Articles

Robotic First Rib Resection With Adjuvant Endovascular Therapy for Chronic Paget-Schroetter Syndrome

BackgroundPatients with acute Paget-Schroetter syndrome (PSS) are treated with endovascular therapy and first rib resection (FRR); however the care of patients with chronic PSS is less well understood. This report describes an emerging approach of robotic-FRR, with adjuvant endovascular therapy, for chronic PSS. MethodsA single-center, retrospective analysis was conducted of patients undergoing robotic-FRR for chronic PSS between 2017 and 2020. Chronic PSS was defined by subclavian vein (SCV) fibrosis identified on duplex ultrasound examination. Patency and clinical outcomes were compared before and after robotic-FRR. ResultsFifteen robotic-FRRs in 14 patients with chronic PSS were analyzed. Median time between acute thrombosis and presentation to our clinic was 167 days. Eleven SCVs were previously treated with anticoagulants only, and 4 had a history of thrombolysis. At the time of presentation, all SCVs displayed chronic thrombosis on duplex ultrasound; 7 (46.7%) were treated with angioplasty followed by robotic-FRR, and 8 (53.3%) proceeded first to robotic-FRR. Postoperative duplex ultrasound examination at a median of 34 days from robotic-FRR demonstrated patency in 5 (33.3%) SCVs. Postoperative angioplasty was performed in 9 (60%) SCVs after a median of 59 days from robotic-FRR, resulting in 6 (40%) additional patent SCVs. The total number of SCVs achieving patency was 11 (73.3%). There were no complications during angioplasties or robotic-FRR. Eleven patients (73.3%) achieved complete symptom resolution with decrease in swelling (P < .001) and pain (P = .016). ConclusionsRobotic-FRR in combination with adjuvant endovascular therapy was associated with favorable clinical and patency outcomes for chronic PSS.

Resection of the entire first rib for giant osteochondroma by trans manubrial approach: a case report and review of the literature

BackgroundFirst rib tumors are extremely rare. Its compression of neurovascularity can easily lead to severe complications such as thoracic outlet syndrome, so early surgical resection is crucial. However, there is no standardized approach to surgery.Case presentationA previously healthy 18-year-old Chinese male undergoes a chest computed tomography (CT) scan that incidentally reveals a raised calcified mass on the right first rib, which is most likely an osteochondroma when combined with magnetic resonance imaging (MRI). We achieved excellent results with resection and thoracic reconstruction by adopting an inverse L-shaped incision in the anterior chest and a longitudinal split of the sternum.ConclusionsOur practice provides great reference for the surgical management of first rib tumors.

Analysis of completion intraoperative venography during first rib resection for venous thoracic outlet syndrome

BackgroundWe evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). MethodsWe performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. ResultsFifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. ConclusionsOur single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.

Thoracic outlet syndrome in overhead athletes

BackgroundWe aimed to retrospectively compare the clinical outcomes of endoscopy-assisted first-rib resection for thoracic outlet syndrome (TOS) between overhead athletes and non-athletes and investigate the return to same-level sports rate in overhead athletes. MethodsWe retrospectively reviewed 181 cases with TOS (75 women, 106 men; mean age, 28.4 years; range, 12–57 years) who underwent endoscopy-assisted first-rib resection. We divided into two groups: 79 overhead athletes and 102 non-athletes groups. A transaxillary approach for first-rib resection and neurovascular decompression was performed under magnified visualization. Endoscopic findings related to the neurovascular bundle, interscalene distance, and scalene muscle were evaluated intraoperatively. We assessed the Roos and Disability of the Arm, Shoulder, and Hand (DASH) scores, return to same-level sports rate, and ball velocity. ResultsOverhead athletes were significantly more likely to be men, younger, used the dominant side more frequently, and have a larger physique, more shoulder and elbow pain, and shorter symptom duration. The outcomes of the Roos score revealed significant differences in excellent or good results between overhead athletes (91.1%) and non-athletes (62.8%). The two groups significantly differed in preoperative and postoperative DASH and recovery rate scores (P = 0.007, < .001, < .001). ConclusionsOverhead athletes with TOS were more likely to be men, younger, dominant side more frequently, and have more shoulder and elbow pain, and a shorter symptom duration. Endoscopy-assisted transaxillary first-rib resection and neurolysis provided superior clinical outcomes in overhead athletes with TOS compared with non-athletes and a high return-to-same-level-play rate in sports.

17 years' experience of surgical management of thoracic outlet syndrome at a district general hospital.

Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular structures passing through the thoracic inlet. It is categorised into three subtypes: neurogenic TOS (NTOS), venous TOS (VTOS) and arterial TOS (ATOS). This study evaluates the outcomes of patients who underwent first rib resection (FRR) for TOS during a period of 17 years at a single district general hospital. Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021. A total of 62 FRRs were performed on 51 individual patients. Indications for FRR included 42 NTOS (68%), 6 VTOS (10%) and 14 ATOS (23%). Thirty-four patients (64%) were female and the mean age at time of surgery was 39 years (range 27 to 64 years). Eleven patients (21%) underwent bilateral FRR and seven cases of cervical ribs were observed. The mean time from initial symptoms to diagnosis was 18 months (range 2 to 60 months). Overall, outcomes after surgery were positive across all subtypes of TOS. Based on Derkash's classification, 52 patients (84%) reported excellent/good, 8 (13%) reported fair and 2 (3%) reported poor resolution of symptoms at 6 month follow-up. Complications included four (9%) pneumothorax, two (4%) wound infections, two (4%) haematoma, one (2%) haemothorax, three (5%) phrenic nerve complications and one (2%) brachial neuropraxia. FRR for TOS can be performed safely and effectively in a district general hospital environment with excellent patient clinical outcomes.

Erector Spinae versus Surgically Placed Pain Catheters for Thoracic Outlet Decompression

Perioperative care after surgery for thoracic outlet syndrome (TOS) involves multimodal pain control. Pain catheters with bupivacaine infusion are a modality to minimize perioperative narcotic use. Our study aims to compare surgically placed pain catheters (SP) with erector spinae pain catheters (ESP) placed by the anesthesia pain service. Retrospective review of a prospectively maintained surgical TOS database identified patients undergoing transaxillary first rib resection (FRR) who had either SP or ESP placed for pain control. Patients were matched for age and gender. Data collected included demographics, operative details, and perioperative pain medication use. Narcotic pain medication doses were converted to milligram morphine equivalents (MME) for comparison between groups. Pain medications were collected for several time points: intraoperatively, for each post-operative day (POD), and for the entire hospital stay. Eighty-eight total patients were selected for comparison: 44 patients in the SP and ESP groups. Patients in each group did not differ with regards to age, BMI, gender, diagnosis, or comorbidities. There were no differences in preoperative narcotic use, preoperative pain score, or QuickDASH score. All patients underwent FRR. Concurrent cervical rib resection was performed in 6.8% SP and 6.8% ESP patients (p=1.00), pectoralis minor tenotomy in 34.1% SP and 29.5% ESP patients (p=0.65), and venogram in 31.8% SP and 31.8% ESP patients (p=1.00). Mean OR time was 90.0 minutes in SP and 105.3 minute in ESP cases (p=0.15). Mean length of stay was 1.9 days for SP and 1.8 days for ESP patients (p=0.56). There were no significant differences in intraoperative narcotics dosing in MME (SC: 22.1 vs ESP: 25.3, p=0.018). On POD 0, there were no differences in total narcotics dosing (MME) (SC: 112.0 vs ESP: 100.7, p=0.59), or in the use of acetaminophen, NSAIDS, or muscle relaxants. A similar trend in narcotics dosing was observed on POD 1 (SP: 58.6 vs ESP: 69.7, p=0.43), and POD 2 (SP: 23.5 vs ESP: 71.3, p=0.23). On POD 1, there was a higher percentage of SP patients taking NSAIDs (63.6% vs 40.9%, p=0.024), however, this difference was not observed on POD 2. There were no differences in acetaminophen or muscle relaxant use on POD 1 or 2. Total hospital stay MME was similar between groups (SC: 215.9 vs ESP: 250.9, p=0.23) CONCLUSION: Pain catheters with bupivacaine infusions are helpful adjuncts in postoperative pain control after FRR for TOS. This study compares SP to ESP, and demonstrates no difference in narcotics use between SP and ESP groups. SC should be used for pain control in facilities which do not have an anesthesia pain service available for ESP placement.

Management of Paget-Schroetter: a Systematic Review and Meta-Analysis

Objective: Effort induced subclavian vein thrombosis, also known as Paget-Schroetter syndrome (PSS) can be treated non-operatively with direct oral anticoagulation (AC), with percutaneous catheter directed thrombolysis (CDT), first rib resection (FRR), or a combination of treatments. Currently, there is no consensus on the optimal management of PSS. The objective of this study was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies. The main questions to be addressed were: Is surgical management of PSS consisting of CDT followed by FRR superior to non-operative management with AC? Does the use of CDT improve the outcomes of non-operative treated patients? Does the use of CDT improve the outcomes of surgical treated patients with PSS?

Considerations for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome: A Meta-Analysis of Patient-Reported Outcomes

It remains unclear whether first rib resection (FRR), performed via a supraclavicular (SCFRR) or transaxillary (TAFRR) approach, is necessary for patients with neurogenic thoracic outlet syndrome (nTOS). In a systematic review and meta-analysis, we performed a direct comparison of patient-reported functional outcomes following different surgical approaches for nTOS. The authors searched PubMed, Embase, Web of Science, Cochrane Library, PROSPERO, Google Scholar, and the gray literature. Data were extracted based on the procedure type. Well-validated patient-reported outcome measures were analyzed in separate time intervals. Random-effects meta-analysis and descriptive statistics were used where appropriate. Twenty-two articles were included, with 11 discussing SCFRR (812 patients), 6 discussing TAFRR (478 patients), and 5 discussing rib-sparing scalenectomy (RSS; 720 patients). The mean difference between preoperative and postoperative Disabilities of the Arm, Shoulder and Hand score was significantly different comparing RSS (43.0), TAFRR (26.8), and SCFRR (21.8). The mean difference between preoperative and postoperative visual analog scale scores was significantly higher for TAFRR (5.3) compared to SCFRR (3.0). Derkash scores were significantly worse for TAFRR compared to RSS or SCFRR. RSS had a success rate of 97.4% based on Derkash score, followed by SCFRR and TAFRR at 93.2% and 87.9%, respectively. RSS had a lower complication rate compared to SCFRR and TAFRR. There was a difference in complication rates: 8.7%, 14.5%, and 3.6% for SCFRR, TAFRR, and RSS, respectively. Mean differences in Disabilities of the Arm, Shoulder and Hand scores and Derkash scores were significantly better for RSS. Higher complication rates were reported after FRR. Our findings suggest that RSS is an effective option for the treatment of nTOS. Therapeutic IV.

Development and validation of a prediction model for outcomes after transaxillary first rib resection for neurogenic thoracic outlet syndrome following strict Society for Vascular Surgery diagnostic criteria

ObjectiveNeurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS. MethodsWe performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation. ResultsA total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers’ compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88). ConclusionsUsing retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.

When Healing Hands Hurt: Epidemiology of Thoracic Outlet Syndrome Among Physicians

Thoracic outlet syndrome (TOS) is an infrequent condition which results in disability in use of upper extremity. While TOS is often associated with manual labor, industrial workers, and accidents, it has not been reported in a physician (MD) population. Given the investment of time and effort in training to become a MD, the impact of TOS may be devastating. Our objective is to report the presentation and outcome of TOS in MDs. A prospectively surgical database was reviewed for MDs who sought care of disabling TOS between 1997 and 2022. Demographic, clinical, outcome and pathological data were reviewed. Outcomes were assessed based on Somatic Pain Scale (SPS), Quick Disabilities of Arm, Shoulder and Hand (DASH) scores, and Derkash scores. Results were also assessed based on return to employment. A total of 19 MDs were identified, from 1,687 TOS cases. The group included 13 (63%) men, 6 (31%) women, average age 45years (range 27-57). Presentations included 1 (5.3%) arterial TOS (ATOS), 9 (47.4%) venous TOS (VTOS), and 9 (47.4) neurogenic TOS (NTOS). All patients were right-handed, and symptomatic side was dominant hand in 7 (37%) patients. Etiologies included repetitive motion injury, athletic injury, and congenital bony abnormalities. Repetitive motion was associated with 3/9 (33%) NTOS. Significant athletic activities were noted in 12 of 19 (63%) MDs, including 8/9 (89%) VTOS and 4/9 (44%) NTOS. Athletic activities associated with VTOS included triathletes (2), rock climbing (1), long distance swimming (2), and weightlifting (3). Of the 9 NTOS cases, 3 were associated with weightlifting and 1 with skiing. Congenital causes included 1 (5%) abnormal first rib and 1 (5%) cervical rib. Time from symptom onset to consultation varied significantly according to diagnosis: ATOS 6days, VTOS 97days, and NTOS 2,335days (P<0.05). All underwent first rib resection (FRR), and 4 (4) patients required contralateral FRR. Time from surgery to last follow-up averaged 1,005days (range: 37-4,535days). On presentation, 6 patients were work disabled and 13 patients were work restricted. Following surgery, 4 MDs remained work restricted with mild to moderate symptoms. After surgery, standardized outcomes (SPS, Quick DASH, and Derkash score) improved in all metrics. All who were initially disabled returned to work without restriction. Significant non-TOS related comorbidities were present in all who had residual restriction. Return to work was documented in all. Although it has not been reported, MDs are subject to developing TOS. Causes include repetitive motions, athletic injuries, and congenital bony abnormalities. Surgical decompression is beneficial with significant reduction in pain and disability. MDs are highly motivated and insightful; accordingly, they have a very high probability of successful work resumption, with all returning to their medical positions.

TH4.7 Seventeen years experience of surgical management of Thoracic Outlet Syndrome at a District General Hospital

Abstract Aims To evaluate the outcomes of patients who underwent first rib resection (FRR) for Thoracic Outlet Syndrome (TOS) over a period of 17 years at a single District General Hospital (DGH). Methods Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021. Results Sixty patients underwent 65 subclavian approach FRR for indications neurogenic (n=45 (69%)), venous (n=6 (9%)), arterial (n=14 (22%)) TOS. Forty-four female patients underwent FRR (68%) and mean age at time of surgery 34 years (range 27 to 64 years). Five patients (7.6%) had bilateral FRR and seven patients (10.6%) diagnosed with cervical rib. Mean length of time from initial symptoms to diagnosis 24 months (range 2 to 60 months). Forty patients (62%) underwent a failed trial of conservative management with physiotherapy before proceeding to surgical management. Fifty-two patients (80%) reported complete resolution of symptoms at follow up. Complications included wound infections 2(3%), pneumothorax 4(6%), haemothorax 1(1.5%), phrenic nerve complications 3(4.6%) and chronic pain 1(1.5%). One patient with phrenic nerve injury underwent diaphragmatic plication procedure with resultant resolution of symptoms. Mean length of stay 1.6 days. Conclusions This series presents the difficulty of diagnosis and management of TOS with the majority of patients enduring symptoms for a prolonged period of time before referral and definitive management. Phrenic nerve complications are an underreported complication of subclavian approach FRR, it is essential to counsel patients accordingly before proceeding to surgery. FRR for TOS can be performed safely and effectively in a DGH environment.

Surgical decompression among Paget-Schroetter patients with subacute and chronic venous occlusion

ObjectiveManagement of Paget-Schroetter syndrome (PSS) with first rib resection (FRR) and venoplasty is successful in re-establishing subclavian vein (SCV) patency in most cases. However, in cases with subacute or chronic venous occlusion, SCV patency may not be achieved. Thus, the role for FRR remains controversial in cases of subacute or chronic SCV occlusion. Our goal is to determine whether FRR is beneficial in PSS patients with subacute or chronic SCV occlusion. MethodsA prospectively maintained thoracic outlet syndrome (TOS) database was searched for patients undergoing FRR who were identified as having SCV occlusion on preoperative venography between 2012 and 2021. Preoperative and postoperative venous patency were determined by venography. Standardized functional outcomes were assessed using the Quick Disability Arm, Shoulder, Hand (QuickDASH—QDS) and Somatic Pain Scale (SPS) before and after FRR. The Derkash outcome score was recorded after FRR. ResultsOver the study period, 966 TOS operations were performed; of these, 401 were for venous TOS, and 33 patients were identified with subacute or chronic preoperative SCV occlusion verified by venography. The median age was 29 years, with 73% men. Eighteen patients had attempted thrombolysis; eight were performed at our institution, and ten performed at a referring facility. The median time from the symptom onset of SCV occlusion to FRR was 78 days for all patients. For the group that achieved venous patency after FRR, the time from SCV occlusion to FRR was 71 days, and it was 106 days for the group that remained occluded after FRR. All underwent postoperative venography and percutaneous attempt at SCV recanalization. Recanalization was successful in 64% (21) and unsuccessful in 36% (12). All patients experienced improvement in SPS and QDS. For all patients, the average SPS improved from 1.69 preoperatively to 0.25 postoperatively and the average QDS improved from 27.63 preoperatively to 10.19 postoperatively (P > .05). For patients who were successfully recanalized, the final SPS was 0.18 and the final QDS was 11.22 (P > .05). In patients who failed to achieve recanalization, the final SPS was 0.40 and the final QDS was 9.06 (P > .05). All postoperative Derkash outcome scores were excellent and good, with none fair or poor. ConclusionsIn patients with subacute or chronic preoperative SCV occlusion, surgical decompression and postoperative angioplasty resulted in re-establishing SCV patency in 64% of patients. Symptomatic patients clinically improve after surgical decompression regardless of whether venous patency is successfully re-established. These results indicate that symptomatic patients with PSS should be considered for TOS decompression even if their SCV is occluded in the subacute or chronic presentation.

Preoperative thrombolysis is associated with improved vein patency and functional outcomes after first rib resection in acute Paget-Schroetter syndrome

IntroductionMost patients with acute Paget-Schroetter syndrome (PSS) present in one of two manners: (1) thrombosis managed initially with thrombolysis and anticoagulation and then referred for surgery, and (2) initial treatment with anticoagulation only and later referral for surgery. Definitive benefits of thrombolysis in the acute period (the first 2 weeks after thrombosis) over anticoagulation alone have not been well reported. Our goal was to compare patients managed with early thrombolysis and anticoagulation followed by first rib resection (FRR) and later postoperative venography with venoplasty (PTA) with those managed with anticoagulation alone followed by FRR and PTA using vein patency assessed with venography and standardized outcome measures. MethodsWe reviewed a prospectively collected database from 2000 to 2019. Two groups were compared: those managed with early thrombolysis at our institution (Lysis) and those managed with anticoagulation alone (NoLysis). All patients underwent FRR. Venography was routinely performed before and after FRR. Standardized outcome measures included Quick Disability of Arm, Shoulder, and Hand (QuickDASH) scores and Somatic Pain Scale. ResultsA total of 50 Lysis and 50 NoLysis patients were identified. Pre-FRR venography showed that thrombolysis resulted in patency of 98% of veins, whereas 78% of NoLysis veins were patent. After FRR, postoperative venography revealed that 46 (92%) patients in the Lysis group and 37 (74%) patients in the NoLysis group achieved vein patency. Thrombolysis was significantly associated with final vein patency (odds ratio: 17 [4-199]; P < .001). Lysis patients had a trend toward lower QuickDASH scores from pre-FRR to post-FRR compared with NoLysis patients with a mean difference of −16.4 (±19.7) vs −5.2 (±15.6) points (P = .13). The difference in reduction of Somatic Pain Scale scores was not statistically significant. ConclusionsThrombolysis as initial management of PSS, combined with anticoagulation, followed by FFR and VenoPTA resulted in improved final vein patency and may lead to an improved functional outcome measured with QuickDASH scores. Therefore, clinical protocols using thrombolysis as initial management should be considered when planning the optimal treatment strategy for patients with acute PSS.

Development and Validation of a Prediction Model for Outcomes After First Rib Resection for Neurogenic Thoracic Outlet Syndrome Using the Society for Vascular Surgery Diagnostic Criteria

Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome (TOS). Yet this disease remains difficult to diagnose and successfully treat. The purpose of this study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR).

A Single Institution 30-Year Review of Abnormal First Rib Resection for Thoracic Outlet Syndrome

Congenital abnormalities of the first rib (ABNFR) are a rare cause of thoracic outlet syndrome (TOS). The range of abnormalities have not been clearly documented in the literature. Surgical decompression in these patients presents with increased complexity secondary to anomalous anatomy. Our goal is to review an institutional experience of first rib resection (FRR) performed for ABNFRs, to present a novel classification system, and to analyze outcomes according to clinical presentation. A prospectively collected database was used to identify individuals with ABNFRs who underwent FRR for TOS between 1990-2021. These individuals were identified both by preoperative imaging and intraoperative descriptions of the first rib after resection. Demographic, clinical, perioperative and pathological data were reviewed. ABNFRs were classified into 3 categories according to anatomical criteria: (I) Hypoplastic, (II) Fused, and (III) Hyperplastic. Outcomes were rated using the standardized Quick Disability of Arm Shoulder and Hand Scores (QDS), Somatic Pain Scores (SPS) and Derkash Scores (DkS). Among the 2200 cases of TOS, there were 19 patients (0.8%) with ABNFR who underwent FRR. Average age at surgery was 30.5 (range 11-74), including 13 men and 6 women. Presentations included 9 arterial (ATOS), 6 neurogenic (NTOS), and 4 venous (VTOS) cases. There were 6 class I, 6 class II, and 7 class III ABNFRs. Among 6 NTOS patients there were 4 abnormal nerve conduction tests and 5 positive anterior scalene muscle blocks. Among the 9 patients with ATOS, thrombolysis was attempted in 5 patients, and of these, 3 ultimately required surgical thrombectomy. Of 4 VTOS cases, 2 were managed with thrombolysis, and 2 with anticoagulation alone. The approach for FRR was transaxillary in all patients. Secondary procedures included 1 pectoralis minor tenotomy, 1 scalenectomy, and 1 contralateral rib resection. No major neurological or vascular complications occurred. There was 1 patient who required surgical evacuation of a hematoma. Intraoperative chest tube placement was required in 5 patients secondary to pleural entry during dissection. There was an overall improvement in symptoms over an average follow-up of 7.4 months. QDS reduced from 49.7 pre-op to 22.1 (P < 0.05). SPS improved from 3.4 pre-op to 1.8. DkS scores were good to excellent in 79% of patients. Residual symptoms were noted in 7, and ATOS accounted for 5 (70%) of these. All patients were able to return to work. Despite increased complexity, ABNFRs may be safely resected via transaxillary approach with low incidence of complications, very good symptom relief, and excellent outcomes. Congenital ABNFRs may by classified into 3 categories (hypoplastic, fused, and hyperplastic) with a variety of presentations, including ATOS, NTOS, and VTOS. Classification of ABNFRs allows concise description of abnormal anatomy which facilitates comparison between series and provides direction for surgical management to ultimately optimize patient outcomes.

A Novel Approach to First-Rib Resection in Neurogenic Thoracic Outlet Syndrome.

Objectives: The treatment for neurogenic thoracic outlet syndrome (NTOS) conventionally involves first-rib resection (FRR) surgery, which is quite challenging to perform, especially for novices, and is often associated with postoperative complications. Herein, we report a new segmental resection approach through piezo surgery that involves using a bone cutter, which can uniquely provide a soft tissue protective effect.Methods: This retrospective study involved the examination of 26 NTOS patients who underwent piezo surgery and another group of 30 patients who underwent FRR using the conventional technique. In the patient group that underwent piezo surgery, the rib was first resected into two pieces using a piezoelectric device and subsequently removed. In the patient group that underwent conventional surgery, the first rib was removed as one piece using a rib cutter and rongeurs.Results: The piezo surgery group had significantly shorter operative time (96.85 ± 14.66 vs. 143.33 ± 25.64 min, P < 0.001) and FRR duration (8.73 ± 2.11 vs. 22.23 ± 6.27 min, P < 0.001) than the conventional group. The posterior stump length of the residual rib was shorter in the piezo surgery group than in the conventional group (0.54 ± 0.19 vs. 0.65 ± 0.15 cm, P < 0.05). There were no significant differences in postoperative complications and scores of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Cervical Brachial Symptom Questionnaire (CBSQ), and the visual analog scale (VAS). Even the TOS index (NTOS Index = [DASH + (0.83 × CBSQ) + (10 × VAS)]/3) and patient self-assessments of both the groups showed no significant differences. Univariate analyses indicated that the type of treatment affected operative time.Conclusion: Our results suggest that piezo surgery is safe, effective, and simple for segmental FRR in NTOS patients. Piezo surgery provides a more thorough FRR without damaging adjacent soft tissues in a relatively short duration and achieves similar functional recovery as conventional techniques. Therefore, piezo surgery can be a promising alternative for FRR during the surgical treatment of NTOS.

Paget Schroetter Patients with Chronic Venous Occlusion Benefit from Surgical Decompression

Management of Paget Schroetter syndrome (PSS) with first rib resection (FRR) and venoplasty is successful in reestablishing subclavian vein (SCV) patency in most cases. However, in cases with chronic venous occlusion, SCV patency might not be achieved. Thus, the role for FRR has remained controversial in cases of chronic occlusion. Our goal was to determine whether FRR is beneficial for PSS patients with an occluded SCV.

Long-term outcome over a decade after first rib resection for neurogenic thoracic outlet syndrome.

The aim was to determine long-term outcomes over a decade after first rib resection (FRR) in patients with neurogenic thoracic outlet syndrome (NTOS). A secondary aim was to investigate correlation of residual rib stump with long-term symptoms. This ambispective cohort included patients who underwent transaxillary FRRs for NTOS between 1998 and 2007. Short-term outcomes at 3-month clinical follow-up were retrospectively collected from medical records. Patients who agreed to participate in the study were invited to a long-term clinical follow-up in 2019. Disabilities of Arm, Shoulder, and Hand Score and Cervical Brachial Symptom Questionnaire were used. A chest X-ray limited to a clavicular projection was taken, and the length of the residual first rib was measured. Twenty patients {mean age 41.8 [standard deviation (SD): 10.3 years]} who underwent 27 FRRs participated in the study. The mean follow-up time was 14.9 (SD: 3.6) years. Excellent or good recovery was noted after 16 (59.3% of operated arms) operations in the short-term follow-up and 22 (81.5%) operations in the long-term follow-up. No reoperations were necessary for residual symptoms. The mean Cervical Brachial Symptom Questionnaire score was 26.7 (SD: 28.2) (maximum 120), and the Disabilities of Arm, Shoulder, and Hand Score was 21.1 (SD: 18.4) (maximum 100) points. Twenty-six patients (96.3%) had a noticeable residual first rib stump. The mean length of the residual first rib was 28.9 (SD: 9.5) mm. More than 30-mm rib stump did not indicate a worse long-term outcome. This study showed good long-term outcome without symptom recurrence after FRR for NTOS. In most patients, after surgery, quality of life and ability to work improved. Residual rib stump length was not associated with the treatment outcome.

A modified supraclavicular approach to scalenotomy without first rib resection for the treatment of neurogenic thoracic outlet syndrome

BackgroundCurrent approaches to scalenectomy for brachial plexus decompression can cause nerve injuries in patients with neurogenic thoracic outlet syndrome (nTOS), especially when first rib resection (FRR) is performed. We describe a modified supraclavicular approach for scalenotomy that reduces the postoperative morbidity of nTOS patients. MethodsThe patient is placed in supine position with the neck slightly extended and turned to the opposite side of the procedure. The modified incision begins above the clavicle 2.5 cm lateral to its first third, extends in medial direction, and turns upwards along the lateral edge of the sternocleidomastoid muscle (SCM) 2.5 cm from the clavicle. Skin flaps are elevated. The external jugular vein is dissected and retracted. The supraclavicular nerves and omohyoid muscle are conserved if found. The phrenic nerve is identified, dissected, and retracted. The anterior scalene muscle is divided, and the brachial plexus is freed. The clinical data and postoperative outcomes of patients that underwent surgery over the last three years were retrieved. The functionality of the arm after surgery was evaluated using the Disabilities of the Arm, Shoulder, and Hand questionnaire in Spanish (DASHe). ResultsSixteen nTOS patients received surgery with one bilateral procedure (17 procedures). Seventy-five percent were females with a median age of 53 years. Obesity and smoking were observed in 43.75% and 37.5% of patients, respectively. No postoperative complications occurred, except for one partial phrenic nerve palsy. All patients reduced their DASHe scores after surgery (mean reduction 41.09 ± 18.37). ConclusionOur modified supraclavicular approach for scalenotomy is safe and improves outcomes in patients with nTOS, reducing the need for FRR.

Endoscopic-Assisted Transaxillary Approach for First-Rib Resection and Neurolysis in Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a complex disorder with signs and symptoms resulting from compression of the brachial plexus and subclavian vessels. Although transaxillary first-rib resection is a well-established surgical treatment for patients with symptomatic TOS, this approach sometimes does not allow adequate exposure of the insertion point of the middle scalene muscle to the posterior part of the first rib and neurovascular bundle. The objective of this Technical Note is to describe an endoscopic-assisted transaxillary approach for first-rib resection and neurolysis. An endoscopic-assisted transaxillary approach for first-rib resection in TOS can provide excellent magnified visualization and safely allow sufficient decompression of the neurovascular bundle.