Vascular thoracic outlet syndrome

Abstract

Vascular thoracic outlet syndrome generally affects young, active, otherwise healthy patients. The diagnosis is suspected by clinical presentation, and can be confirmed with angiography or venography. Conservative management has been associated with significant morbidity and long-term residual disability. We have used a multimodal treatment protocol that includes thrombolysis, anticoagulation, surgical decompression, and interventional procedures. Catheter-directed recombinant tissue-type plasminogen activator and intravenous heparin infusion are instituted at the time of diagnosis to promote recanalization and prevent propagation of thrombus. Surgical decompression of the thoracic outlet can be readily achieved by first rib resection during the same hospitalization. Postoperative venograms are obtained in all patients. Residual stenoses can be managed with angioplasty alone in some patients but more commonly require stent placement. We believe thrombolysis, anticoagulation, surgical decompression, and percutaneous interventions act synergistically to improve results of therapy in patients with vascular thoracic outlet syndrome.

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

“…The most outstanding advantage of piezo surgery is its soft tissue protective effect. Owing to the close relationship between the first rib and soft tissues ( 8 ), traditional FRR via the supraclavicular approach is usually associated with soft tissue injury, including pneumothorax ( 9 , 10 ), neurovascular bundle injury ( 18 , 36 ), sympathetic chain injury ( 9 ), and lymph leakage ( 11 – 16 ). In our study, there were no reports of soft tissue injury in the piezo surgery group.…”

“…Previous studies defined first-rib resection (FRR) as the most demanding and potentially dangerous component of TOS surgery (6,7). A close relationship between the first rib and soft tissue can be associated with soft tissue injury, including pneumothorax (with an incidence of 2.5-10%), lymph leakage (incidence of 2-9.3%), and nerve injury (incidence of 11%) (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). Therefore, several methods for the minimal invasive resection of the first rib have been reported including video assisted thoracic surgery (VATS), and robotic-assisted thoracic surgery (19,20).…”

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“…The most outstanding advantage of piezo surgery is its soft tissue protective effect. Owing to the close relationship between the first rib and soft tissues (8), traditional FRR via the supraclavicular approach is usually associated with soft tissue injury, including pneumothorax (9,10), neurovascular bundle injury (18,36), sympathetic chain injury (9), and lymph leakage (11)(12)(13)(14)(15)(16). In our study, there were no reports of soft tissue injury in the piezo surgery group.…”