Subclavian Vessels Research Articles

Neurosurgery of the peripheral nervous system: entrapment syndromes of the brachial plexus

Entrapment of the brachial plexus (BP) can be primary or secondary to either trauma or surgery. Most frequently, the BP is entrapped at the “thoracic outlet” resulting in thoracic outlet syndrome (TOS). Hyperabduction syndrome, scalenus anterior (or anticus) syndrome, costoclavicular syndrome, cervical rib syndrome, and long-C7 transverse process syndrome are all entrapment syndromes of the BP. These last terms are used either independently or as part of TOS, although “true TOS” is due to an alteration of the soft tissues at the thoracic outlet and not to bone causes. In 1956, Peet et al. [4] introduced the term TOS to describe a clinical picture with signs and symptoms due to compression of the BP and subclavian vessels at the thoracic outlet. The etiology and clinical presentation of BP entrapment syndromes, including TOS, are variable; diagnosis may be difficult, and treatment is controversial. Knowledge of the anatomy, clinical presentation, diagnostic tools and therapeutic options is very important for correct diagnosis and therapy.

胸郭出口症候群に対する脊椎外科学的検討

A prospective study was carried out to determine the clinical and radiological characteristics of thoracic outlet syndrome (TOS), whose patients presented neurological or vascular symptoms in the upper extremity from the compression of the brachial plexus or subclavian vessels. Twenty-six patients with cervical disc disease (C-group), 36 patients with TOS (T-group), and 18 patients with cervical disc disease combined with TOS (CT-group) were compared on sex, age, weight, symptoms and radiological findings. The T-group had younger females with lean posture. In the radiographs of the T-group, cervical lateral X-Ps in the neutral position showed the inferior margin of the T1 vertebrae as the lowest level and kyphotic malalignment. The range of motion in the flexion and extension views was maintained and anterior-posterior views revealed the lower position of the clavicle. The total spinal lateral X-P in TOS patients demonstrated faulty posture and anterior deviation of the gravity line at the C5 level. The common evidence between the CT-group and the C-group suggested that the pathogenesis of the secondary TOS is caused by cervical disc diseases.

Surgical Management of Superior Sulcus Tumors

Superior sulcus tumor refers to any primary lung cancer presenting with constant pain in the nerve distribution of the eighth cervical, first and second thoracic nerve roots and Horner's syndrome caused by invasion of the stellate ganglion. The pain is steady, severe, and unrelenting, involving the shoulder, the vertebral margin of the scapula and ulnar distribution of the arm to the elbow and finally to the ulnar surface of the forearm, and the small and ring fingers of the hand (Pancoast-Tobias syndrome). Weakness and atrophy of the hand muscles can also occur as the lesions spreads to involve the first and second ribs and vertebrae. Radiologically, there is a small shadow at the extreme apex of the lung with rib and possible vertebral body invasion. Pulmonary symptoms are less frequent because of the peripheral location of the lesions. Since Shaw and Paulson approached superior sulcus tumors in 1961 by using preoperative radiation-therapy (30 to 45 Gy in four weeks including the primary tumor, mediastinum and supraclavicular region) followed by surgical resection, this radiosurgical approach shortly became the standard treatment yielding better disease control and survival than that offered by other treatment modalities. It has now become evident that en bloc resection of the chest wall, involved adjacent structures as well as lobectomy must be considered the standard surgical approach for superior sulcus tumors combined with external radiation (preoperative, postoperative, or both). The goal of the operation is the complete and en bloc resection of the upper lobe in continuity with the invaded ribs, transverse processes, subclavian vessels, T1 nerve root, upper dorsal sympathetic chain and prevertebral muscles.

Three-dimensional MR angiography in the evaluation of thoracic outlet syndrome.

The objective is to present our initial experience with the combination of three-dimensional time-resolved contrast-enhanced MR angiography and T1-weighted spin-echo imaging for investigation of vascular compression related to thoracic outlet syndrome. In patients with clinical signs of thoracic outlet syndrome suggesting vascular elongation or compression, this technique proves to be robust, and its results are comparable to those of conventional catheter angiography. Our results allow precise identification of the anatomic structure(s) responsible for the clinical symptoms and show the effect of arm hyperabduction on the patency of the subclavian vessels.

Subclavian Stents and Stent-Grafts: Cause for Concern?

To report cases of stent and stent-graft fracture in the subclavian vessels. Three patients with self-expanding stents of 3 different types in 1 subclavian artery and 2 subclavian veins presented with recurrent symptoms 6 months to 2 years after stenting. All devices showed signs of compression with stent fracture. The covered stent in the subclavian artery was excised. Of the 2 venous patients, 1 was treated with first rib resection and the other refused further treatment. The subclavian vessels are prone to flexion during movement, and the vessels may be compressed by external structures, including the clavicle and first rib. Stents that have not been designed to withstand these forces may be damaged.

Penetrating injuries to the subclavian and axillary vessels

Background: Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels. Study Design: Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period. Results: Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location. Conclusions: Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.

Traumatic subclavian and axillary vessel injuries

In an analysis of medical records on upper limb vascular trauma over a 9-year period (1989–1997) at Istanbul Faculty of Medicine's Surgical and Medical Emergencies Department, it was found that 28 patients required surgery for subclavian or axillary vessel injuries. Of these, 20 cases (71.4%) were the result of penetrating and 8 cases (28.5%) were the result of blunt injury. Eight patients had an associated brachial plexus lesion. Patients were treated by either primary repair (50%), saphenous vein graft interposition (41.6%), or ligation (14.2%). Overall mortality rate was 14% (four cases). No long-term vascular sequela occurred related to the vascular repair techniques. However, the long-term outcome of brachial plexus lesions was poor in four patients. Therefore, the outcome of upper limb injury is not dependent on the vascular injury which can be successfully managed. The long-term consequences are determined by the associated orthopedic, soft tissue, and nerve injuries.

Thoracic outlet syndrome (TOS) and pulmonary embolism (PE): report of two cases

Thoracic outlet syndrome (TOS) results from the compression of the subclavian vessels and the brachial plexus. Chronic compression of the vessels leads to pulmonary embolism (PE). We present our experience of two patients with PE due to TOS. Two patients (1 male, 1 female), both weightlifters, were admitted to our intensive care unit with severe hypoxaemia, dyspnoea and respiratory alkalosis. Both patients had a medical history of multiple attacks of chest pain and pain in the right arm. The clinical picture, a ventilation/perfusion scan and digital subtraction angiography confirmed the diagnosis of PE. We present this rare complication of the syndrome and give guidelines for optimal management and treatment.

Aggressive management of vascular injuries of the thoracic outlet

Purpose: We present a review of 35 patients who underwent an operation for subclavian (n = 18) or axillary (n = 17) vessel injury. In some patients, both an artery and a vein were damaged, resulting in a total of 30 arterial and 16 venous injuries. Methods: The wounding source included a gunshot (n = 19), a stab wound (n = 9,) and blunt trauma (n = 7). Seven patients had hypotension and were taken immediately to the operating room. Seventeen patients had diminished or absent pulses, whereas 13 patients had normal pulses despite an arterial injury. Associated injuries included nerve injury (n = 15), pneumohemothorax (n = 5), and fractures (n = 7). Angiography in 21 patients demonstrated an intimal flap (n = 8), extravasation (n = 5), a pseudoaneurysm (n = 3), an arteriovenous fistula (n = 2), and occlusion (n = 1). Two angiograms were normal. Arterial repair was accomplished by interposition graft (n = 17), primary repair (n = 9), patch angioplasty (n = 3,) and ligation (n = 1). Results: No functional deficits occurred in patients with an isolated vascular injury. Seven patients with associated brachial plexus injuries experienced severe disability. One arm of a patient was amputated. Two patients died. Conclusions: The use of angiography helps to confirm and localize injuries. Prompt correction of the vascular injury avoids disability resulting from ischemia. Although the amputation rate is low with vascular repair, the functional disability resulting from associated nerve injuries can be devastating. (J Vasc Surg 1998;27:880-5.)

Traumatic Vascular Disruption in the Thoracocervical Region: Surgical Outcome and Predictors of Survival

Traumatic vascular injury in the thoracocervical region is associated with significant morbidity and mortality. The goal of this study was to examine surgical outcome of these injuries and to establish predictors of survival. The medical records of all patients sustaining traumatic injury to the carotid, vertebral, subclavian, and proximal axillary vessels and undergoing operative repair were retrospectively reviewed. Sixteen patients (11 men, 5 women, mean age 31.1 ±16.6) during a four-year period underwent emergent surgical repair for traumatic vascular disruption. There were 6 lesions of the carotid, 7 of the subclavian, and 2 of the proximal axillary vessels and 1 vertebral artery injury. Sixty- two percent of the patients were hemodynamically unstable on admission. In these patients the diagnosis was established by clinical examination. Hemodynamically stable patients with a high index of suspicion for vascular injury underwent urgent arteriog raphy to confirm the diagnosis and assist in the operative approach. Surgical procedures included lateral arteriorrhaphy (2), end-to-end anastomoses (2), synthetic interposition grafts (3), and autogenous vein graft (2). Seven patients underwent emergent ligation of the subclavian, carotid, or vertebral artery. Despite 3 of 16 patients presenting in either unresponsive shock or with severe head trauma, overall mortality was 25%. Nonsurvivors had significantly higher injury severity scores than survivors (36.3 ±13.1 vs 19.8 ±7.9, P &lt; 0.05). Length of time from trauma scene to hospital was a significant predictor of survival (33.4 ± 13.3 vs 50.8 ±6.5 minutes) as was the presence of associated organ system injury (2.8 ±0.9 organ systems vs 4.3 ±0.9, P &lt; 0.05) in survivors and nonsur vivors, respectively. No neurologic compromise or limb ischemia was noted in the group undergoing arterial ligation. Among similarly injured vessels, the type of surgical repair did not influence patient survival. The outcome of surgical repair of a traumatic lesion of the thoracocervical vessels depends upon the rapid recognition of the injury, time delay to the trauma unit, and the magnitude of associated injury.

Hemothorax - A Complication of Subclavian Vein Cannulation

Massive bleeding into pleural cavity after subclavian vein cannulation is a rather rare but very serious complication. Usually laceration of the venous wall is the cause. In patients where conservative treatment, i.e. pleural drainage, maintaining the circulatory volume, treatment of possible coagulopathy, etc. is ineffective, surgery has to be performed. Bleeding can be surgically managed either from posterolateral thoracotomy or direct subclavian vessel revision is possible after partial resection of the clavicle. Brachiocephalic vein bleeding can be approached and managed through median sternotomy. We present a case report of 22-year old man with hemothorax after subclavian vein cannulation. In our patient only complex surgical procedure enabled proper management of bleeding complication.

Major vessel resection during limb-preserving surgery for soft tissue sarcomas.

There is uncertainty in the literature as to whether major vessel involvement in extremity soft tissue sarcomas constitutes an indication for amputation. This retrospective review includes 21 patients who underwent major vessel resection in the context of limb preservation for soft tissue sarcomas. Resected vessels were the common iliac in one, external iliac and common femoral in six, common and superficial femoral in five, superficial femoral in six, distal superficial and popliteal in two, and subclavian vessels in one. Wound infection occurred postoperatively in five patients (24%). One Gore-tex and one vein graft became exposed, but the wounds healed by secondary intention with routine wound care. Three patients (14%) manifested local recurrence, of which one required an amputation. The estimated 5-year survival rate is 63%. Involvement of major vessel(s) by soft tissue sarcomas of the extremities is not in itself an indication for amputation, as with en bloc resection of major vessels the local recurrence and 5-year survival rates parallel those of patients with soft tissue sarcomas not requiring major vessel resection.

Magnetic resonance imaging of neurogenic tumors of the thoracic inlet: determination of the parent nerve.

To investigate the value of magnetic resonance imaging (MRI) in determining the parent nerves of neurogenic tumors in the thoracic inlet, analysis of MR images was performed in nine patients with surgically resected neurogenic tumors in the thoracic inlet (two neurofibromas and one schwannoma of the vagus nerve, three schwannomas of the brachial plexus, and two schwannomas and one ganglioneuroma of the sympathetic nerves). These MR images were compared with surgical and pathologic findings. The multidirectional capability and excellent tissue contrast of MRI facilitated recognition of the location, shape, and extent of the tumors. MRI, which permitted an easy understanding of the spatial relation between the tumors and the subclavian vessels, scalenus muscles, and brachial plexus, was useful in determining the nerves of origin. Two neurofibromas, four of six schwannomas, and one ganglioneuroma were recognized to extend along the axes of the parent nerves on MR images. MRI is useful in determining the parent nerve of neurogenic tumors in the thoracic inlet and is helpful in planning surgical treatment of these tumors.

Thoracic outlet: an anatomical redefinition that makes clinical sense.

The diagnosis of thoracic outlet syndrome (TOS) is intrinsically difficult, and the literature about it is full of confusing terminology. Symptoms may arise due to compression of neural and/or vascular elements in one or more of three different locations. A number of tests were developed during the early part of this century, and a variety of syndromes have been described that relate to these tests, all of which are now considered to be subtypes of the thoracic outlet syndrome. Yet anatomists and clinicians fail to agree on even the definition of the thoracic outlet. It is proposed that anatomists not use the term thoracic inlet as a synonym for the superior thoracic aperture, nor thoracic outlet for the inferior thoracic aperture. What many clinicians call the thoracic outlet should be called the scalene triangle by both anatomists and clinicians, divisible into a lower portion to be called the thoracic outlet (for subclavian vessels and nerve roots C.8 and T.1) and an upper portion, the cervical outlet (for nerve roots C.5, C.6, and normally C.7). What is currently called thoracic outlet syndrome should be renamed the cervicoaxillary syndrome (CAS), divisible into three subtypes: thoracic outlet, costoclavicular, and pectoralis minor syndromes. Compression of the upper roots of the brachial plexus between the anterior and middle scalene muscles should be recognized as cervical outlet syndrome, and all terms containing the word scalenus should be discarded.

Thoracic outlet: An anatomical redefinition that makes clinical sense

The diagnosis of thoracic outlet syndrome (TOS) is intrinsically difficult, and the literature about it is full of confusing terminology. Symptoms may arise due to compression of neural and/or vascular elements in one or more of three different locations. A number of tests were developed during the early part of this century, and a variety of syndromes have been described that relate to these tests, all of which are now considered to be subtypes of the thoracic outlet syndrome. Yet anatomists and clinicians fail to agree on even the definition of the thoracic outlet. It is proposed that anatomists not use the term thoracic inlet as a synonym for the superior thoracic aperture, nor thoracic outlet for the inferior thoracic aperture. What many clinicians call the thoracic outlet should be called the scalene triangle by both anatomists and clinicians, divisible into a lower portion to be called the thoracic outlet (for subclavian vessels and nerve roots C.8 and T.1) and an upper portion, the cervical outlet (for nerve roots C.5, C.6, and normally C.7). What is currently called thoracic outlet syndrome should be renamed the cervico-axillary syndrome (CAS), divisible into three subtypes: thoracic outlet, costoclavicular, and pectoralis minor syndromes. Compression of the upper roots of the brachial plexus between the anterior and middle scalene muscles should be recognized as cervical outlet syndrome, and all terms containing the word scalenus should be discarded. © 1996 Wiley-Liss, Inc.

Resection of a superior sulcus tumor: Ginsberg RJ. Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Ctr., 1275 York Avenue, New York, NY 10021. Chest Surg Clin North Am 1995;5:315–331

All of these approaches are valuable and worthwhile, depending on the site of the apical tumor (anterior or posterior). When using an anterior approach, however, if significant posterior chest wall involvement is also present, a combined approach may be necessary, turning the patient after closure of the anterior wound, and completing the excision from the posterior approach. Thoracic surgeons involved in the management of these tumors should have all of these approaches available in their armamentarium. The overall 5-year cure rate following surgical resection of superior sulcus tumors is about 30%. In our experience, when a complete resection is performed, including a lobectomy, the 5-year cure rate is doubled. The results of en bloc resection of adjacent involved organs (subclavian vessels, vertebral body) are less optimistic in most reported series, which may reflect inadequate resections.

Modified trap-door thoracotomy for malignancies invading the subclavian and innominate vessels.

Thirteen patients with malignancies which had invaded the subclavian vessels and/or distal border of the innominate vessels were operated on through modified "trap-door" thoracotomy. The modification is the additional resection of the first rib from inside the thorax. Tumors consisted of thyroid cancer in 5 patients, thymic tumor in 3, Pancoast tumor in 3, and lymphoma in 2. Invaded vessels were on the left side in 9 cases, on the right in 3, and bilateral in one. Subclavian and/or innominate veins were resected in 12 cases and reconstructed in 5. The remaining case was treated with resection of the right innominate and subclavian artery and its vascular reconstruction. Compared to original trap-door thoracotomy, the modification provided a more adequate opening in the chest wall and more extensive exposure of the entire subclavian vessels, which made distal vascular control safe and easy. Postoperative complications occurred in one patient, who suffered chylothorax. In conclusion, modified trap-door thoracotomy is a viable and useful approach in the resection of malignancies which have invaded the subclavian and/or distal border of the innominate vessels.

Modified Anterior Approach to the Cervicothoracic Junction

This study reports the experience with four patients regarding a modified anterior approach to the cervicothoracic junction. This technique was evaluated with respect to extent of exposure, ease of technique, and postoperative morbidity. Previously reported anterior approaches to the cervicothoracic junction have described either full sternotomy resection of the left sternoclavicular junction or osteotomy of the clavicle. A simplified approach was chosen using a partial sternotomy, which has not been described previously for approaches to the spine. Four patients with metastatic disease, in the region of the cervicothoracic junction, required decompression and stabilization for palliation of symptoms. An anterior approach was required for decompression. A standard cervical approach was combined with a partial median sternotomy and transverse osteotomy through the synostosis between the manubrium and body of the sternum. In three patients, the left innominate vein was divided. Decompression and anterior stabilization were followed by posterior stabilization at an interval of 4 to 7 days. This procedure was simple to perform, requiring little additional operative time for opening or closure. It provided excellent exposure from C3-T4. There was no associated morbidity related to the division of the manubrium or innominate vein. Partial sternotomy combined with a standard cervical incision provides excellent exposure to the cervicothoracic junction from C3-T4. It is technically simple to perform and avoids the risk of injury to subclavian vessels inherent in resection of the clavicle or sternoclavicular junction. There is no additional morbidity associated with this approach.

Giant bilateral fibrous dysplasia of first ribs: compression of mediastinum and thoracic outlet

A 43 year old woman presented with two large bilateral tumours of the first ribs that compressed the right subclavian vessels, trachea and oesophagus and led to right arm oedema, severe dyspnoea and dysphagia. The resected tumours showed typical histological features of fibrous dysplasia without malignant transformation. The right tumour weighed 1.5 kg and measured 17 x 13 x 10 cm. This report demonstrates that major surgery is still possible for resection of such exceptional giant compressive lesions, since fibrous dysplasia is a benign and non-infiltrative tumour.

Primary stent deployment in occlusive subclavian artery disease.

Primary (without antecedent balloon dilation) Palmaz stent implantation was successfully performed in 27 consecutive patients entering with 31 obstructed subclavian arteries. Stents (n = 50) were successfully deployed, using the brachial (n = 7), femoral (n = 16), or combined (n = 8) approach, to revascularize 31 subclavian vessels [8 occluded (26%); 23 stenotic (74%)], using a 6 or 7.5 French delivery system. The indications for intervention were arm claudication in 8 patients (30%), subclavian steal syndrome in 11 patients (41%), angina pectoris secondary to impaired blood flow to the left internal mammary artery coronary bypass in 6 patients (22%), and recanalization of a left subclavian occlusion to permit central arterial access and performance of a second interventional procedure 2 patients (7%). The percent diameter stenosis improved from 85 +/- 12% to 6 +/- 7% (P < 0.001); and, the peak and mean translesion gradients decreased, respectively, from 56 +/- 35 mm Hg to 3 +/- 4 mm Hg (P < 0.01), and 29 +/- 18 mm Hg to 2 +/- 2 mm Hg (P < 0.01). Procedural complications encountered were one stent dislodgement with migration into and uneventful deployment within the right external iliac artery, and two brachial artery repairs. No acute vessel closures, deaths, myocardial infarctions, cerebrovascular accidents, transient ischemic attacks, or need for transfusions occurred. Therefore, primary subclavian artery stent deployment can be performed using low-profile sheath systems with excellent success (100%), resulting in immediate restoration of pulsatile flow, and few complications. The incidence of lesion recurrence remains for follow-up studies.