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ORIGINAL ARTICLE
Year : 2022 | Volume
: 9
| Issue : 5 | Page : 349-352
Arterial thoracic outlet syndrome - Clinical presentation, surgical management, and outcome: An institutional experience of 10-year period
Harish Kumar Ayyavoo, B Vella Duraichi, Narayanan Sritharan, K Jayachander, Paramasivam Ilayakumar, S Prathap Kumar, R Ranjith Babu, M Ramya, P Jan Sujith
Department of Vascular Surgery, Madras Medical College, RGGGH, Chennai, Tamil Nadu, India
Correspondence Address:
Dr. Harish Kumar Ayyavoo
Department of Vascular Surgery, Madras Medical College, RGGGH, Chennai, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_84_22
Objective: The main objective of this study was to review the clinical presentations, surgical management, and outcome of surgical procedures for arterial thoracic outlet syndrome (TOS). Methodology: This is a retrospective analysis of arterial TOS patients admitted in our department (Institute of Vascular Surgery, Madras Medical College, Chennai) from August 2012 to July 2022. Results: This study enrolled 81 patients, with mean age of 41.13 (12-65 years) and 50.61% male (41) and 49.39% female (40), associated with distal arterial lesions - 63 (77.77%), among which 50.61% - occlusion in the brachial artery (33), 24.69% in forearm arteries (15), and 24.69% in the axillary artery (15). About 95.06% of patients had cervical rib (77), 2.46% - first rib abnormality (2), 2.46% - soft-tissue compression (2), 59.25% was SCHER Stage III (48), 33.33% SCHER stage I (27), and 7.40% SCHER stage II (6). All patients had undergone a supraclavicular approach. The most common arterial lesions were subclavian artery (SCA) thrombus in 53.08% (43), occlusion in 17.28% (14), and dilatation in 29.62% (24) cases. The cervical rib excision with anterior scalenectomy in 95.06% (77), and 1st rib excision with anterior scalenectomy 2.46% (2) and soft tissue resection with anterior scalenectomy 2.46% (2) of patients. SCA intervention/reconstruction was done in 88.88% (72) of cases. Two patients had underwent above elbow amputation (2.46%) and no mortality and SCA patency was 100%. Conclusion: Cervical rib excision with anterior scalenectomy with or without thrombectomy is an effective procedure for arterial TOS cases.
Keywords: Cervical rib, interposition graft, intimectomy, subclavian aneurysm, thoracic outlet syndrome
Thoracic outlet syndrome (TOS) is a term used to describe a group of disorders that occur when there is compression, injury, or irritation of the nerves and/or blood vessels (arteries and veins) in the lower neck and upper chest area. Among them, Arterial TOS is <1 % of TOS cases. This external compression results in repeated trauma in the intima of the subclavian artery (SCA), resulting in subclavian stenosis, thrombosis, and aneurysm formation with mural thrombus and distal embolization.[1],[2] The morbidity of arterial TOS is severe that warrants immediate attention and management. Arterial complications of TOS are uncommon, but they are potentially more severe; and in some cases, they may lead to the loss of a limb. Surgery is the best option in arterial TOS. The approach is either a supraclavicular or transaxillary approach. The surgical treatment contains scalenectomy with or without cervical rib excision, first rib excision, and resection of any constraining band or soft tissue, in addition to the management of SCA diseases such as thrombectomy, endarterectomy, and aneurysm resection with bypass.
Materials and MethodsAims and methods
This is a retrospective analysis of arterial TOS patients admitted in Institute of Vascular Surgery, Madras Medical College, Chennai, from August 2012 to July 2022. In this study, 81 patients were studied who presented with upper limb ischemic features due to compressive symptoms in the thoracic outlet region. Patients with atherosclerotic lesions, neurogenic TOS, and primary Raynaud's phenomenon were excluded from the study. The main objective of this study was to review the clinical presentations, surgical management, and outcome of surgical procedures for arterial TOS.
MethodsEvaluation
Patient had evaluated by careful history and physical examination such as supraclavicular fullness and pulse examination and distal ischaemic changes [Figure 1]a. Then, we measure the brachial, radial, and ulnar artery pressure using hand Doppler to confirm the level and severity of ischemia. A cervical spine X-ray was obtained as a means of identifying certain anatomic abnormalities such as cervical rib/anomalous first rib (callus/malunion)/clavicular malunion [Figure 1]b. The patient was further evaluated by duplex scan and CT angiogram [Figure 1]c in case of distal occlusion. Magnetic resonance imaging is used to identify the soft-tissue lesion if there is no cervical rib in X-rays.
Figure 1: Arterial TOS: Clinical finding & investigations (cxr & cta): a) distal embolization b) chest x-ray-showing b/l cervical rib c) cta-showing-post stenotic dilatationSurgery
All patients were approached through the supraclavicular route. After incising the skin, platysma scalene pad of fat was mobilized superolaterally and phrenic nerve was preserved. Anterior scalene muscle was identified and divided. SCA control was taken. In all cases, the cervical rib was excised along with the soft-tissue structures compressing the artery. According to the type of lesion and the level of embolization, intimectomy with SCA suturing with either thrombectomy through SCA or brachial artery was performed. Patients with distal occlusion bypass were performed using synthetic or venous grafts.
Outcome
Postoperatively, all patients are assessed for clinical improvement. Clinical assessment of the results for arterial reconstruction included examination for any evidence of digital emboli or ischemia, bilateral upper extremity blood pressures, and duplex scan. All patients were followed up monthly up to first 3 months, then once in 3 months in 1st year, and once in a year till the date. On selection, each case is studied in detail, and the data were collected using the proforma.
ResultsClinical presentation
In this study, 81 patients had taken and all had undergone surgical decompression. In this study, the age of the patients ranged between 12 and 65 years (mean age – 41.13). Out of the 81 patients, 41 (50.61%) were males and 40 (49.39%) were females. A cervical rib was identified by preoperative chest X-ray in 77 (95.06%) cases and the first rib in 2 (2.46%) cases [Figure 1]. Two (2.46%) cases with no bony abnormalities had magnetic resonance imaging which showed soft tissue compressing the SCA [Figure 2]. The associated distal arterial lesion is found in 63 (77.77%) of cases [Figure 3]. The most common distal site of occlusion is brachial artery 33 (40.74%), followed by axillary 15 (18.52%) and forearm arteries 15 (18.52%). CT angiogram shows 48 (59.26%) were in Scher III, 27 (33.3%) patients were in scher I, and 6 (7.41%) patients were SCHER-II.
Results-surgical treatment
All patients underwent thoracic outlet decompression through the supraclavicular approach. Seventy-two (88.88%) of patients had undergone SCA intervention [Figure 4]. The arterial lesions found in SCA thrombus in 53.08% (43), occlusion in 17.28% (14), and dilatation in 29.62% (24) cases [Figure 5]a, [Figure 5]b. Cervical rib excision [Figure 5]e with anterior scalenectomy in 95.06% of patients, first rib in 2.46% patients and anterior scalenectomy and soft tissue resection in 2.46% patients. Intimectomy with thrombectomy through SCA was done in 30 (37%) patients. Intimectomy was performed in eight (9.87%) patients [Figure 5]c. Thirty-three (40.8%) of patients underwent concomitant brachial thrombectomy [Figure 5]d at the time of intimectomy. Direct SCA reconstruction was performed in ten (12.34%) of patients with interposition bypass grafting using synthetic graft dilatation (8.64%) in seven patients and reverse saphenous vein in three (3.69%) patients [Table 1].
Figure 5: Intra-OP findings & surgical interventions a) post-stenotic dilatation b) sca aneursym c) sca intimectomy d) brachial thrombectomy e) cervical rib excisionOutcome
There was no perioperative and postoperative mortality. The overall limb salvage rate is 97.53%. SCA patency was 100%. Two (2.46%) patients had undergone above-elbow amputation. There were 5 (6.17%) finger amputations and 12 (14.87%) phalangeal-level amputations [Figure 6]. 2 (2.46%) developed hematoma postoperatively and managed.
DiscussionEarly diagnosis and aggressive treatment of arterial complications of TOS are indicated to prevent disabling upper extremity ischemia and even digital gangrene. In this study, the age of the patients ranged between 12 and 65 years (mean age –41.13). Out of the 81 patients, 41 were males and 40 were females. In our study, male and female ratio is more or less equal compared to other studies which show female preponderance. In a report by Adson,[3] it was 72% were women and 23% were men. In other studies also, there is female preponderance attributed to the presence of cervical ribs more in females than in males.[4] The presence of the cervical rib itself does not mean arterial TOS, so an increased number of cervical ribs in females does not mean an increased number of arterial TOS in females. Toso et al.[5] also found that patients who had only the cervical rib removed without the first rib removed continued to have symptoms after the operation. We found that removing the cervical rib and anterior scalenectomy is an effective treatment. We found no evidence of increased morbidity or mortality in patients who received resections of the cervical rib. Supraclavicular approach is best for cervical rib excision and for gaining access to the SCA.[3],[6],[7] A combined supraclavicular and infraclavicular approach has also been suggested to allow for access to both the subclavian and axillary arteries, but four of our patients who had arterial reconstruction required a dual approach.[8],[9],[10],[11],[12] In our study-bypass patency is 100%. In other series bypass patency is reported in the range of 90-100% depending patency of the outflow.[13] In our study-limb salvage in 100% in Scher I & II & 95.83% in Scher III.
ConclusionThe arterial TOS – though rare presentation, increased morbidity of the disease by thromboembolic events warrants immediate attention and management. Surgery is the best option in arterial TOS cases presented with thromboembolic events. Supraclavicular approach was the best approach and cervical rib excision with anterior scalenectomy with or without thrombectomy is an effective procedure for arterial TOS cases.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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