Objectives: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures supplying the upper extremity as they exit through the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. The transaxillary (TA) approach has been the preferred approach, although the supraclavicular (SC) approach has become more widely used, especially when adjunct procedures are required. Our objective was to review the results with both approaches in our institution.Methods: A retrospective review of patients who underwent thoracic outlet decompression between 2009 and 2014 at the University of Iowa Hospitals and Clinics was conducted. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected preoperatively. Operative times, hospital length of stay, perioperative complications, and outcomes were also studied.Results: During the study period, 82 thoracic outlet decompression procedures were performed: 48% were for neurogenic TOS, 46% for venous TOS, and 6% for arterial TOS. Thirty-nine patients (47.5%) underwent the TA approach, and 43 (52.5%) underwent the SC approach. Adjunct procedures were performed in 16% of patients in addition to decompression, 85% of which were in the SC group. There was a significant difference in average operative time between TA and SC (124.5 vs 157 minutes; P < .05) but no differences in hospital length of stay. Minor complications were seen in 20% of patients, with no significant difference between the TA and SC groups. Major complications occurred in 6%, with four patients (3 TA and 1 SC) requiring re-exploration. There were no perioperative or 30-day deaths. On follow-up, 37% of patients with neurogenic TOS had complete resolution of symptoms, 54% had partial improvement, and 9% had no improvement. In both the venous and arterial TOS groups, 66% had complete symptom resolution and 34% had partial resolution. There was no difference in symptom resolution between the TA and SC groups.Conclusions: There is no significant difference between TA and SC approaches for TOS in perioperative complications, length of stay, and improvement of symptoms. Although operative time appears to be longer in the SC group, this can be attributed to adjunct procedures, including vascular reconstructions performed using this approach.

Objective: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex ultrasound stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation (SI), whether surveillance with ADSI yielded a better outcome than in those with only anklebrachial index (ABI) follow-up.Methods: We performed a retrospective analysis of all patients undergoing SFA SI for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI (ADSI group) and those with ABI follow-up only (ABI group). Life-table analysis comparing stent patency, major adverse limb event (MALE), limb salvage, and mortality between groups was performed.Results: There were 248 patients with SFA SI included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous regarding clinical indication (claudication/critical limb ischemia, ADSI 39%/61% vs ABI 38%/62%; P ¼ .982) and TransAtlantic Inter-Society Consensus classification (A/B/C/D for ADSI 17%/45%/16%/22% and ABI 21%/43%/16%/20%; P ¼ .874). Primary patency (PP) was similar between groups at 12, 36, and 56 months (ADSI, 65%/43%/32%; ABI, 69%/34%/34%; P ¼ .770), whereas ADSI patients showed an improved assisted PP (84%/68%/54%) vs ABI (76%/38%/38%; P ¼ .008) and secondary patency (Fig 1). There was a greater freedom from MALE in the ADSI group (91%/76%/64%) vs the ABI group (79%/46%/46%; P < .001) at 12, 36, and 56 months of followup. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA SI intervention (P ¼ .001), whereas ABI patients were more likely to undergo an amputation (P < .001; Fig 2).Conclusions: In SFA SI, patients with ADSI follow-up demonstrate an advantage in assisted PP and secondary patency and are more likely to undergo an endovascular reintervention. These factors likely effected a decrease in MALE, indicating the benefit of a more universal adoption of post-SFA SI follow-up ADSI.

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