Thoracic Outlet Sx

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Arterial omplications ofThoracOutlet SyndromeLAZAR B. DAVIDO VIC M.D. P H . D . , IGOR B. KONCAR M.D. SINISA D. PEJKIC M .D. ILIJA B. KUZM ANOV IC M.D.

From the Clinic for Vascular Surgery Institute for Cardiovascular Diseases of theSerbian Clinical Centre Belgrade SerbiaArteria com plications of thoracic outlet com pression have serious potential implica tions; how -ever, these complications rarely appear. Between 1990 and 2006, prospectively collected data on 27patienls with arterial complications of thoracic outlet syndrome were analyzed. The causes ofarterial com pression were cervical rib (20 [74.1% ), abn orm alities of the first thoracic rib (three[11.1%]), soft tissu e ano ma lies (two I7.4%1), and h ype rtro ph ie ca llus after clavicle fracture (tw o[7.4%]). In all cases, a com bined suprac lavicular and infraclavicular ap proach was use d. D ecom-pression was achieved by cervical rib excision in 13 (48.1%) patients, combined cervical and firstrib excision in seven (26%), and first rib excision in six (22.2%). Associated vascular proce duresinclud ed resec tion and replac em ent of the subclavia n artery (26 [97.3%]), one subc lavia n-ax illaryand one axillar y-brac hial by pas s as well as 17 (63%) brachia l emb olectom ies. The mean follow-upperiod was7 years4 months (range, 1-16 years). Two pleural entries, two transient brachial plexusinjuries, and one subclavian artery rethrombosis were found. Complete resolution of symptomswith a return to full activity was noted in all cases. In surgical treatment, a combined anteriorsupraclavicular and infraclavicular approach is recommended as well as transbrachial embolectomyin all cases with symptoms of distal embolization.

N 1958. CHARLES ROB defined thoracic outlet syn-drome (TOS) as a "set of symptoms that may existdue to compression on the brachial plexus and onsubclavian vessels in the region of the thoracic out-let." Although arterial complications of thoracicoutlet compression are present in less than 5 per cent ofoperations performed for TOS. these complicationshave great medical importance because of their seriousprognostic im plications. In 1905. Murphy first per-formed successful resection of the cervical rib in apatient with TOS and subclavian artery aneurysmusing a supraclavicular approach.'^-^This article presents surgical therapy of arterial TOS.

Materials and MethodsBetween 1990 and 2006, prospectively coH ected dataon 27 patients with arterial complications of TOS wereanalyzed. There were 17 female (63%) and 10 (37%)male patients with an average age of 36.1 years. Bonyabnormalities were causative factors in 25 (92.6%) ofour cases with arterial TOS. The cervical rib was foundin 20 (74.1%) cases, congenital abnormalities of the firstthoracic rib in three (11.1%), and hypertrophie callusAddress correspondence and reprint requests to Lazar B.D avidovic. M.D .. Clinic for Vascular Surgery. Institute for Car-diovascular D iseases of the Serbian Clinical Ce nter. 8 K. Todor-

after neck-shoulder trauma and clavicle fracture in two(7.4%) cases. In two (7.4%) of our cases, there were nocongenital or acquired bone abnormalities, so soft tissueabnormalities were probably the cause of the thoracicoutlet compression.

Thirteen (48.1%) patients had subclavian arteryaneurysms that contained an intraluminal thrombus(Fig. 1). Two (7.4%)) subclavian artery dilatations and12 (44.4%) subclavian artery stenoses were associatedwith mural thrombus (Fig. 2). Seventeen (63%) caseshad associated distal arterial embolization.Sixteen (59.3%) patients presented with handischemia caused by distal embolization. One (3.7%)patient had transient ischmie attack attributable toretrograde cerebral embolism through the right carotidartery. Ten (37%) patients had claudications andvasomotor phenomena during only arm hyperabductioncaused by com pression of the subclavian artery (Fig. 3).In all 27 cases, a combined supraclavicular-infraclavicular approach was used during the oper-ation. Surgical treatment included a decompressionprocedure and arterial reconstruction. D ecom pressionwas achieved by cervical rib excision in 13 (48.1%)cases; by simultaneous excision of both cervical ribsand first thoracic ribs in seven (25.9%) cases; and byexcision of the first rib in seven (25.9% ) cases . D ivi-sion of all muscular and fibrous structures at the


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F I G . 1. M ) Postoperalive specimen ofresected subclavian artery aneurysm in thepiiticnl uilii thoracic outlet syndniiiic. ()The nuira thrombu.^ at ihc resected andopened aneurysni. (C) Preoperalive arte-riograni shows ihe aeutc cmholie i>cc usionofih bellow the elbow arteries lopen blackarrow) in ihe same paticnt-

Fi(. 2. (A) Preoperative arleriogram of apatient with poslstenolie dilatation of the sub-ciiivian artery (biack arrow in 4) secondary tothoraeie outlcl syndrome, (if) Postoperativespecimen shows mural thrombus at Ihe resectedand opened artery. (C) The open while irrowshows an ulcerated plaque at the point of com-pression ot" the subclavian atlery (open blackarrow inA) by a ecrvical rib.

After decompression. reconstructive vascularprocedures were perlbrmed. They included resectionand repair oi the subclavian atlei^ in25(96.3%) cases(13 aneurysnis, Iwo dilatations, and 10 stenoses), one(3.7%) subclavian-axillary repair (without arterialresection), and one (3.7%) axillary-brachial bypass(with associated stibclavian resection and replacement).Associated brachial embolectomy was necessary in 16cases. After resection, reconstruction of the subclavianartery was performed by end-to-end anastomosis in five(19.2%) cases, with a poly te trail uoroethy lene graft in

16 (61.5%) cases. Four subciavian-axillary and axil-lary-brachial bypasses with saphenous vein graft werepedbrmed (Fig. 4 B).Control examinations included physical. Doppler. andduplex ultrasonography, which were peribmied 1.6. and12 months after the operation and once a year thereafter.Results

No postoperative deaths occurred in our study. Fourearly complications were found. Two (7.4%) pleural


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Fifi. 3. Ane riogr i i i of ihc lel sub-ckiv i im i i r icry In l l ic palienl wi lh thonici i ;oui l syndrome. {A No injury is seenwhen the arm is placet in a neutral posi-t ion . (Z) In the ?.anic paiicnt. liiere iscomplete obslruclion of the suhckivianurtery is seen (open white arrow) when thearm is placed in hypcrabduction.

I G 4. Operative specimens afterdecompression ofthe thoracic oullel: siib-davian artery aneurysm resection andreplacement with an expanded polytetra-lluoroethylene ePTFE gralt {AY. sub-ciavian~a\illary bypass with saphcnousvein graft without arterial resection {B .

patietits with transient brachial plexus injuries recoveredcompletely after physical treatment, whereas one (3.4%)early arterial relhromhosis required reoperation.The mean duration of follow up was 7 years 4months (range, 1-16 years). In this follow-up period,al leconstructed arteiies were patent. A completeresolution of symptotns with a return to full activitywas noted in all patients.Discussion

Patients with arterial symptoms constitute only a

population with neurovascular com pression at ihe regionof the thoracic outlet."* However, photoplethysmo-graphic recordings in 60 per cent of normal subjectsshowed significant arterial obstruction at the thoracicoutlet during Adson. costoclavicular. or hyperabductionmaneuvers.^ Also, standard anatomic examinationshowed a significant number of thoracic outlet anatom icabnormalities in the general population.''^Thotaeic outlet sytidrome is frequently caused bycongenital or acquired abnormal anatomy ofthe thoracicoutlet area.^' Among arterial thoracic outlet patients, 88


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238 THE AMERICAN SURGEON March 2 9 Vol. 75

bony abnormalities are the most frequent causativefactors. The cervical rib is present in mosl patients wilharterial coinplications of TOS ' ^ (20 of our case s).Arterial consequences are most frequent when the com-plete cervical rib is present.*^ ' ^ Other bony anomaliesthat can produce mierial compression are long seventhcervical transverse processes, partial cervical ribs, andfirst rib abnormalities such as focal protuberances andpronounced widening or arching that narrows the cost-oclavicular space. Congenital abnormalities of the firstthoracic rib (three patients in our study) are less commonthan those ofthecervical ribs but, when present, seem tobe an even more frequent cause of arterial complicationsrelative to cervical ribs.' '-^ Hypertrophie ca llus ol' ahealed clavicular fracture (more frequently) or the firstthoracic rib (rarely) can also cause arterial compressionat the thoracic outl et .^ ' '- We encountered tw o casesthat occuiTed after a clavicular fracture. Arterial TOScaused by a Hrst rib tumor also has been described.'^ Intwo of our cases, there were no congenital or acquiredbone abnormalities. Isolated congenital fibromuscularbands as well as a hypertrophie anterior scalene musclehave been described in a small number of patients witharterial TOS.'^-'

Long-standing compression of the subclavian arterymay lead to various arterial lesions, including stenosiswithout or with mural thrombus (12 of our cases),poststenotic dilatation (two of our cases), and post-stenotic aneurysm 13of our cases).' * '''Thes e chronicarterial changes carry a substantial risk of complica-tions in terms of repetitive multiple distal arm, fore-arm, and/or hand arterial embolisms, leading to acutehand ischem ia and digital gangrene.'' -'' -'^' -' Noless than 16 patients in our series showed such com-plicated findings on initial presentation. Minor digitalmicroembolizations may antedate a major embolieevent for months oryears.- '-' *Retrograde propagationof thrombotic masses from subclavian into vertebral orcarotid vessels may even result in cerebral embo-lism.'^-^ In our practice, we have noted one such case.Subacute or chronic upper extremity ischemia is usu-ally produced by proximal segmental subclavian arteryocclusion with good collateral circulation. In some ofthese cases, arm claudications and vasomotor phenom-ena are provoked by only forced hyperabduction- -^(10 patients in our series).

Treatment of arterial TOS is indicated for allsymptomatic patients (hand ischemia) and asympto-matic patients with documented arterial lesions.Treatment requires simultaneous surgical proceduresfor each of the three anatomic components of thedisease process: arterial compression substrate, sub-clavian and/or axillary arterial lesions, and distalemboli.'^-'^--'* ^'' An ideal surgical approach should

subprocedures. The transaxillary approach is usedmostly for an isolated first rib resection in the presenceof neurologic TOS.-*-^^-^ Treatment of TOS byremoval of the first rib and related compressive struc-tures through the poste rior approach is also described. *^We prefer the combined anterior supraclavicularinfraclavicular approach because it offers completeexposure to the subclavian artery, the cervical and firstthoracic ribs as well as all muscular and fibrous bands inthe thoracic outlet area.^ '- We find that this approachenables a relatively simple and safe resection of thecervical and first ribs, any additional decompression asneeded, and reconstruction of the subclavian artery. *Obligatory decompression procedures include com-plete resection of a cervical and/or abnormal firstthoracic rib together with all abnormal muscular andfibrous structures that are causing or may causeentrapment of regional vessels. In that regard, resectionoftheanterior scalene muscle prevents its reattachmenand may reduce the risk of recurrent compression.

Subclavian artery reconstruction is necessary in thepresence ofanarterial poststenotic dilatation or aneurysmor stenotic lesions with mural thrombosis. Often the arteryappears nonnal externally, but after it is opened, anulcerated intimai lesion is identified. If replacement of thesubclavian arteiy is planned, it can be resected first tofacilitate exposure of tbe bony elements and reduce therisk of intraoperative embolization. The most commonmethods of arterial repair are end-to-end anastomosis(five of our cases) and graft replacement (21 of ourcases).''^-'^ Endovascular treatment of subclavian arteryaneurysm caused by TOS also is described.-''' However18 months later, significant stenosis oftheimplanted stengraft, probably caused by continued extemal com-pression, was found. Only a decompression prcx'edureand endoluminal arterial grafting performed simulta-neously could be an alternative procedure to open vas-culai' surgery in selected patients.-^ ^ in the setting of distalembolization, revascularization must be followed withthromboembolectomy and/or regional thrombolytic therapy (16 of our cases). When distal embolizationischroniand cannot be resolved by simple embolectomy, distabypass is indicated. Standard bypass techniques use asubclavian. a common ciu'otid, and an axillaiy aitery as aninfiow and a saphenous vein as a graft (four of our cases).

ConclusionsArterial TOS is less frequently seen than the neurologic variety of the syndrome. However, because ofits potential for serious limb- and even life-threatening

complications. TOS requires surgical treatment inmost cases. On the basis of our experience with 27patients, we recommend a combined supraclavicular


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exposure of cervical and first thoracic ribs as well asany muscular and fibrous abnormalities and Ihe sub-clavian artery for subsequent reconstruction. In casescomplicated by distal embolization, transbrachialembolectomy provides successful additional revascu-larization of the upper extremity.

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