A 33-year-old female, 32 weeks and 1 day gestation, with known placenta accreta who presented to the emergency department with 2 h of severe abdominal pain, nausea and vomiting. She became hypotensive and underwent emergency cesarean section. Emergency general surgery was consulted for placement of a resuscitative endovascular balloon for aortic occlusion (REBOA). After successful delivery, the balloon was inflated in zone 3 and systolic blood pressure rose from 70 to 170 mmHg. The patient underwent hysterectomy for ongoing hemorrhage. The patient was taken to the surgical intensive care unit. The patient was noted to have pulses following removal of the sheath. Arterial brachial indices and arterial duplex was performed 48 h after sheath removal. The patient was found to have complete occlusion of the right external iliac artery. Vascular surgery was consulted and cut-down performed with thrombus removal via fogarty catheter. The patient was discharged 2 days later without further complication.

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deviation [SD], 11.8 years); 59.7% were female. The majority (80.8%) had neurogenic TOS with venous and/or arterial components based on clinical presentation and/or radiologic evidence; 16.5% had isolated venous TOS; and 2.7% had isolated arterial TOS. Most common symptoms were paresthesia (78.1%), pain (66.9%), and weakness (55.4%); a prior history of trauma was present in 19.6%. Paget-Schrotter Syndrome was the presentation in 60/260 (23.8%) e one-third of these were treated with subclavian vein thrombolysis, with a median time from thrombolysis to decompression being 119 (interquartile range [IQR], 98-270) days. Six (2.3%) presented with acute or chronic limb-threatening ischemia. Three (1.2%) underwent redo-decompression in the context of prior incomplete decompression and persistent symptoms. Surgical approach was supraclavicular in 99.2% and paraclavicular for arterial reconstruction in 0.8%. Adjunctive procedures included accessory cervical rib resection (12.3%); long C7 resection (2.7%); subclavian artery reconstruction (1.5%); and arterial thrombectomy (0.4%). Mean hospital length of stay was 3.4 days (SD, 2.8 days). Most common 90-day complications were pleural effusion requiring thoracostomy tube (5.0%), pneumonia (3.8%), chyle leak (3.1%), transient long-thoracic nerve neuropraxia requiring intensive physiotherapy (1.2%), and hemothorax requiring re-intervention or thoracostomy tube (1.2%) (Table ). There were no perioperative mortalities. Rates of 90-day readmission and emergency room visit were 3.9% and 8.5%, respectively. After a mean follow-up of 202 days (SD, 273 days), 93.3% of patients reported improvement or resolution of TOS symptoms.Conclusions: Supraclavicular decompression in patients with neurogenic, venous, and/or arterial TOS can be performed safely with low perioperative event rates. Careful patient selection and a comprehensive approach to decompression are keys to achieving optimal outcomes.

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