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Creisher BA, Jackson J, Sica S, Rossini E, Biscetti F, Ali M, Salvatore D, Abai B, Nooromid M, DiMuzio PJ. Analysis of Completion Intraoperative Venography During First Rib Resection for Venous Thoracic Outlet Syndrome. J Vasc Surg Venous Lymphat Disord 2024:101936. [PMID: 38945363 DOI: 10.1016/j.jvsv.2024.101936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (vTOS). METHODS We performed a retrospective, single-center review of all patients with vTOS treated with First Rib Resection and intraoperative venography from 2011 - 2023. We reviewed intraoperative venographic films to classify findings, collected demographics, clinical and perioperative variables, and clinical outcomes. Primary endpoints were symptomatic relief and primary patency at 3 months and 1 year. Secondary endpoints were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS Fifty-one AxSCVs (49 patients, mean age of 31.3 ± 12.6, 52.9% female) were treated for vTOS with first rib resection and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Prior to FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with No Stenosis (Group 1, 31.3%), 17 with No Stenosis after Angioplasty (Group 2, 33.3%), 10 with Residual Stenosis after Angioplasty (Group 3, 19.7%), and 8 with Complete Occlusion (Group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (Group 1: 14 of 16, Group 2: 13 of 17, Group 3: 10 of 10, and Group 4: 7 of 8; Log-Rank Test, p = 0.5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (Group 1: 16 of 16 and 9 of 9; Group 2: 16 of 17 and 12 of 13; Group 3: 10 of 10, 5 of 5; Group 4: primary patency not obtained). There was one asymptomatic re-thrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. CONCLUSION Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief, short- and mid-term patency despite residual venous stenosis and complete occlusion. While completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.
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Affiliation(s)
- Brandon A Creisher
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Julian Jackson
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Simona Sica
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrica Rossini
- Unit of Vascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Biscetti
- Unit of Vascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mohammed Ali
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Dawn Salvatore
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Michael Nooromid
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Paul J DiMuzio
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.
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Farquharson BJM, Collis J, Jaskani S, Bergman H, Andrews B. 17 years' experience of surgical management of thoracic outlet syndrome at a district general hospital. Ann R Coll Surg Engl 2024; 106:51-56. [PMID: 36779445 PMCID: PMC10757880 DOI: 10.1308/rcsann.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 02/14/2023] Open
Abstract
INTRODUCTION Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular structures passing through the thoracic inlet. It is categorised into three subtypes: neurogenic TOS (NTOS), venous TOS (VTOS) and arterial TOS (ATOS). This study evaluates the outcomes of patients who underwent first rib resection (FRR) for TOS during a period of 17 years at a single district general hospital. METHODS Retrospective review of patient notes of individuals treated with FRR from August 2004 to August 2021. RESULTS A total of 62 FRRs were performed on 51 individual patients. Indications for FRR included 42 NTOS (68%), 6 VTOS (10%) and 14 ATOS (23%). Thirty-four patients (64%) were female and the mean age at time of surgery was 39 years (range 27 to 64 years). Eleven patients (21%) underwent bilateral FRR and seven cases of cervical ribs were observed. The mean time from initial symptoms to diagnosis was 18 months (range 2 to 60 months). Overall, outcomes after surgery were positive across all subtypes of TOS. Based on Derkash's classification, 52 patients (84%) reported excellent/good, 8 (13%) reported fair and 2 (3%) reported poor resolution of symptoms at 6 month follow-up. Complications included four (9%) pneumothorax, two (4%) wound infections, two (4%) haematoma, one (2%) haemothorax, three (5%) phrenic nerve complications and one (2%) brachial neuropraxia. CONCLUSIONS FRR for TOS can be performed safely and effectively in a district general hospital environment with excellent patient clinical outcomes.
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Affiliation(s)
| | | | | | - H Bergman
- Cambridge University Hospitals NHS Foundation Trust, UK
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Sen I, DeMartino R, Bjarnason H, Neisen M, Kalra M. Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget Schroetter Syndrome. Ann Vasc Surg 2023; 95:210-217. [PMID: 37285964 DOI: 10.1016/j.avsg.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/21/2023] [Accepted: 05/28/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome- PSS) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT) followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer based upon response. The aim of this study was to evaluate outcomes of this flexible protocol. METHODS Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. Endpoints included success of TL and eventual clinical outcome. Patients were divided into 2 groups-Group I: TL/PMT + TOD; Group II: medical management/anticoagulation + TOD. RESULTS PSS was diagnosed in 114 patients; 104 (62 female, mean age 31 years) who underwent TOD were included in the study. Group I: 53 patients underwent TOD after initial TL/PMT (23 at our institution and 30 elsewhere) with success (acute thrombus resolution) in 80% (n = 20) and 72% (n = 24) respectively. Adjunctive balloon-catheter venoplasty was performed in 67%. TL failed to recanalize the occluded SCV in 11% (n = 6). Complete thrombus resolution was seen in 9% (n = 5). Residual chronic thrombus in 79% (n = 42) resulted in median SCV stenosis of 50% (range 10% to 80%). With continued anticoagulation, further thrombus retraction was noted with median 40% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range 2-8 months). Rethrombosis of the SCV occurred in 3 patients 1-3 days postoperatively and was managed with MT/SCV stenting/balloon angioplasty and anticoagulation. Symptomatic relief was achieved in 49/53 (92%) patients at a median follow-up of 14 months. Group II: 51 patients underwent TOD following medical treatment elsewhere with anticoagulation alone for an average 6 months (range 2-18 months) with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (76%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in 4 patients (7%); the indication for TOD being residual symptoms from compression of collateral veins, the median residual stenosis was 70% (range 30-90%). TOD was performed at a median of 6 months after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in 4 patients and stenting in 2. Symptomatic relief was achieved in 46/51 (90%) at a median follow-up of 24 months. CONCLUSIONS For Paget Schroetter syndrome a management protocol encompassing elective thoracic outlet decompression at a convenient time following thrombolysis is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the subclavian vein and may reduce the need for open venous reconstruction.
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Affiliation(s)
- Indrani Sen
- Vascular and Endovascular Surgery, Mayo Clinic Health Systems, EauClaire, WI.
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Haraldur Bjarnason
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Melissa Neisen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Vuoncino M, Humphries MD. How I do it. Thoracic outlet syndrome and the transaxillary approach. J Vasc Surg Cases Innov Tech 2023; 9:101128. [PMID: 37125342 PMCID: PMC10140152 DOI: 10.1016/j.jvscit.2023.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/13/2023] [Indexed: 05/02/2023] Open
Abstract
Thoracic outlet syndrome (TOS) is a disease pattern that involves compression of neurologic venous or arterial structures as they pass through the thoracic outlet. TOS was first described as a vascular complication arising from the presence of a cervical rib. Over time, a better understanding of TOS has led to its wide range of presenting symptoms being divided into three distinct groups: arterial, venous, and neurogenic. Of the known cases, the current estimates of the incidence of neurogenic TOS, venous TOS, and arterial TOS are 95%, 3%, and 1%, respectively. The different types of TOS have completely different presentations, requiring expertise in the diagnosis, management, and treatment unique to each. We present our evaluation, diagnosis, and management method of TOS patients, with specific attention paid to the transaxillary approach.
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Affiliation(s)
| | - Misty D. Humphries
- Correspondence: Misty D. Humphries, MD, Division of Vascular Surgery, Department of Surgery, University of California Davis Health, 2335 Stockton Blvd, NAOB 5001, Sacramento, CA 95811
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Schropp L, Vonken EJ, de Borst GJ. Re: "Medium Term Outcomes of Deep Venous Stenting in the Management of Venous Thoracic Outlet Syndrome". Eur J Vasc Endovasc Surg 2023; 65:763. [PMID: 36707022 DOI: 10.1016/j.ejvs.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Ludo Schropp
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Evert-Jan Vonken
- Department of Interventional radiology, University Medical Center Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands.
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Dadashzadeh ER, Ohman JW, Kavali PK, Henderson KM, Goestenkors DM, Thompson RW. Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome). J Vasc Surg 2023; 77:879-889.e3. [PMID: 36442701 DOI: 10.1016/j.jvs.2022.11.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/02/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS). METHODS We performed a retrospective, single-center review of 266 patients who had undergone primary surgical treatment of VTOS between 2016 and 2022. The clinical outcomes were compared between the patients in four treatment groups determined by intraoperative venography. RESULTS Of the 266 patients, 132 were male and 134 were female. All patients had a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range, 12-66 years). The timing of clinical presentation was acute (<15 days) for 132 patients (50%), subacute (15-90 days) for 71 (27%), and chronic (>90 days) for 63 patients (24%). Venography with catheter-directed thrombolysis or thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 patients (71%). The median interval between symptom onset and surgery was 78 days. After paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%). However, 26 (10%) had a long chronic AxSCV occlusion with axillary vein inflow insufficient for bypass reconstruction. Patch angioplasty was performed for focal AxSCV stenosis in 55 patients (21%) and bypass graft reconstruction for segmental AxSCV occlusion in 35 (13%). The patients who underwent external venolysis alone (patent or occluded AxSCV; n = 176) had a shorter mean operative time, shorter postoperative length of stay and fewer reoperations and late reinterventions compared with those who underwent AxSCV reconstruction (patch or bypass; n = 90), with no differences in the incidence of overall complications or 30-day readmissions. At a median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling, and only 17 (6%) were receiving anticoagulation treatment; 95% of those with a patent AxSCV at the end of surgery were free of arm swelling vs 69% of those with a long chronic AxSCV occlusion (P < .001). The patients who had undergone CDT at the initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery (30% vs 44%; P = .034) and 60% less likely to have arm swelling at follow-up (5% vs 13%; P < .05) vs those who had not undergone CDT. CONCLUSIONS Paraclavicular decompression, external venolysis, and selective AxSCV reconstruction determined by intraoperative venography findings can provide successful and durable treatment for >90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt usage of CDT, and even more effective surgical treatment.
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Affiliation(s)
- Esmaeel Reza Dadashzadeh
- Center for Thoracic Outlet Syndrome, Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - J Westley Ohman
- Center for Thoracic Outlet Syndrome, Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Pavan K Kavali
- Section of Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Karen M Henderson
- Center for Thoracic Outlet Syndrome, Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Danita M Goestenkors
- Center for Thoracic Outlet Syndrome, Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Robert W Thompson
- Center for Thoracic Outlet Syndrome, Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; Section of Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO.
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Thorne CM, Yildirim B, Tracci MC, Chhabra AB. Vascular Problems in Elite Throwing Athletes. J Hand Surg Am 2023; 48:68-75. [PMID: 36266148 DOI: 10.1016/j.jhsa.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/12/2022] [Indexed: 11/05/2022]
Abstract
There are approximately 880 and 3,600 major league baseball and minor league baseball players who currently are active in their respective leagues, with thousands of players in the collegiate, high school, and little league ranks. Although relatively uncommon, vascular injuries, such as thoracic outlet syndrome, axillary artery compression, quadrilateral space syndrome, and direct vascular trauma, can afflict these players. These career- and limb-threatening injuries can mimic often seen muscular sprains and strains in their early stages with nonspecific symptoms, such as exertional fatigue, which can delay diagnosis with disastrous sequelae, including thrombus propagation, aneurysm rupture, and ischemia from distal embolization. The goal of this review is to discuss the pathophysiology, diagnosis, and treatment of these injuries to increase awareness of sport-related vascular phenomena among the hand and upper-extremity surgery community because these players typically are seen first in the training room or a hand specialist's office.
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Affiliation(s)
| | | | - Margaret C Tracci
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
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Krasiński Z, Pukacki P, Begier-Krasinska B. Subclavian Effort and Upper Limb Thrombosis – a Lesson Learned. PHLEBOLOGIE 2022. [DOI: 10.1055/a-1930-9714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
AbstractSubclavian vein effort and upper limb thrombosis, known as the Paget-Schroetter syndrome (PSS), accounts for 30–40 % of spontaneous upper extremity deep vein thromboses (UEDVTs) and 10–20 % of all upper limb deep vein thromboses (DVTs). As complication of PSS include post-thrombotic syndrome and pulmonary embolism, early recognition and prompt initiation of anticoagulant treatment is crucial in the course of its treatment. PSS is associated with single or repeated physical activity of the upper limb, combined with obstruction of venous outflow resulting from anatomical alterations. A correct diagnosis, based on a range of imaging methods, and prompt initiation of local thrombolytic therapy, surgical decompression of the thoracic outlet (when necessary), and immediate initiation of anticoagulant treatment, aim to effectively restore the patient life quality, preventing post-thrombotic syndrome and recurrent thrombosis.
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Affiliation(s)
- Zbigniew Krasiński
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Poznań University of Medical Sciences, Poznań, Poland
| | - Piotr Pukacki
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Poznań University of Medical Sciences, Poznań, Poland
| | - Beata Begier-Krasinska
- Department of Hypertensiology, Angiology and Internal Medicine, Poznań University of Medical Sciences,
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de Boer M, Shiraev T, Saha P, Dubenec S. Medium Term Outcomes of Deep Venous Stenting in the Management of Venous Thoracic Outlet Syndrome. Eur J Vasc Endovasc Surg 2022; 64:712-718. [PMID: 36028006 DOI: 10.1016/j.ejvs.2022.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 08/09/2022] [Accepted: 08/13/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Venous thoracic outlet syndrome (vTOS) is a relatively rare condition associated with significant morbidity. Its management continues to evolve, with increasing use of endovascular adjuncts, such as percutaneous thrombectomy and angioplasty, in addition to first rib resection. The utility of stenting residual venous stenotic lesions is poorly defined within the literature. This study sought to review the medium term patency rates of upper limb deep venous stenting in the management of vTOS. METHODS A single centre, retrospective review of patients managed for vTOS with first rib resection followed by upper limb deep venous stenting between January 2012 and February 2021 was conducted. Post-procedural ultrasounds were reviewed to determine stent patency. RESULTS Twenty-six patients were included, with 33 stents placed. The median duration of follow up was 50 months. On venous duplex ultrasound at three years post-operatively, primary patency rates were 66%, primary assisted patency rates were 88%, secondary patency rates were 91%, and total occlusion rates were 9%. After stent placement, 80% of patients remained asymptomatic with regard to compression symptoms. CONCLUSION Upper limb deep venous stenting is an effective adjunct to surgical decompression in the management of vTOS. Stent medium term patency rates are promising; however, further studies with longer follow up and larger cohorts with multicentre results are required to confirm these early findings.
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Affiliation(s)
- Madeleine de Boer
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | - Timothy Shiraev
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Prakash Saha
- Academic Department of Surgery, School of Cardiovascular Medicine & Sciences, British Heart Foundation of Research Excellence, King's College London, London, UK
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
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Panther EJ, Reintgen CD, Cueto RJ, Hao KA, Chim H, King JJ. Thoracic outlet syndrome: a review. J Shoulder Elbow Surg 2022; 31:e545-e561. [PMID: 35963513 DOI: 10.1016/j.jse.2022.06.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.
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Affiliation(s)
- Eric J Panther
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christian D Reintgen
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Harvey Chim
- Department of Plastic and Reconstructive Surgery, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
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Huang Y, Abad-Santos M, Iyer RS, Monroe EJ, Malone CD. Imaging to intervention: Thoracic outlet syndrome. Clin Imaging 2022; 89:23-36. [PMID: 35689965 DOI: 10.1016/j.clinimag.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/21/2022] [Accepted: 06/06/2022] [Indexed: 11/03/2022]
Abstract
Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.
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Affiliation(s)
- Yijin Huang
- Emory University, Atlanta, GA, United States of America
| | - Matthew Abad-Santos
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Ramesh S Iyer
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Christopher D Malone
- Mallinckrodt Institute of Radiology at Washington University School of Medicine, St. Louis, MO, United States of America.
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Taneva GT, Muñoz Castellanos J, Donas KP. Aetiology and Therapeutic Options of Acute Subclavian Vein Thrombosis. VASCULAR AND ENDOVASCULAR REVIEW 2022. [DOI: 10.15420/ver.2021.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Gergana T Taneva
- Vascular Surgery Department, Puerta de Hierro and Montepríncipe University Hospitals, Madrid, Spain; Vascular Surgery Department, Asklepios Klinik Langen, Frankfurt, Germany
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Abstract
Venous thoracic outlet syndrome represents a relatively rare but important diagnosis in the adolescent population with increasing recognition. Compression of the subclavian vein within the costoclavicular space can lead to episodic venous outlet obstruction in the upper extremity, with edema, rubor and functional symptoms. Over time, cumulative injury and compression can lead to thrombosis of the vein, referred to as "effort thrombosis" or the Paget-Schroetter syndrome. This progression can lead to the need for acute management of the venous thromboembolism, requirement for thoracic outlet decompression surgery and the potential for long-term sequelae such as post-thrombotic syndrome. Management is focused on clot minimization, anticoagulation during the period of endothelial injury and inflammation and surgical decompression via first rib resection, anterior scalenectomy and venolysis to remove external compression of the vein. This manuscript reviews the diagnosis, evaluation and treatment of venous thoracic outlet syndrome and Paget-Schroetter syndrome.
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Affiliation(s)
- Biren P Modi
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, USA.
| | - Rush Chewning
- Division of Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Riten Kumar
- Division of Hematology and Oncology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Uceda PV, Feldtman RW, Ahn SS. Long-term results and patient survival after first rib resection and endovascular treatment in hemodialysis patients with subclavian vein stenosis at the thoracic outlet. J Vasc Surg Venous Lymphat Disord 2021; 10:118-124. [PMID: 34020110 DOI: 10.1016/j.jvsv.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/05/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Hemodialysis patients with upper extremity vascular access and subclavian vein stenosis at the thoracic outlet can present with significant arm edema and threatened dialysis access that is frequently refractory to endovascular therapy without bone decompression. We have presented our long-term results of first rib resection, followed by endovascular therapy. METHODS We performed a retrospective review of 15 consecutive hemodialysis patients with subclavian vein stenosis treated with first rib resection and endovascular therapy from 2013 to January 2021. The diagnosis was confirmed by ultrasound and venography. Bone decompression was performed with transaxillary or infraclavicular rib resection. RESULTS During the study period, we treated 1440 unique dialysis patients. Of these 1440 patients, 346 had undergone subclavian vein angioplasty. Of the 346 patients, 15 had undergone first rib resection and were the subject of the present report. Of the 15 patients, 10 were women and 5 were men. Their mean age was 56.4 years (range, 30-82 years). The most commonly associated medical conditions were hypertension and diabetes. The mean previous hemodialysis duration was 5.4 years (range, 1-13 years). Fourteen patients had preexisting functioning access and severe arm edema. Nine patients (60%) with subclavian vein occlusion had undergone vein recanalization before the bone decompression procedure. Of the 15 patients, 5 had undergone transaxillary and 10 had undergone infraclavicular first rib resection. In addition, nine patients had undergone simultaneous vein stenting, six had undergone vein stenting within 4 weeks, and one had undergone stenting at 13 months. A stent-graft was used in eight patients and a bare metal stent was used in seven. All preexisting dialysis access sites were used the day after the procedure. The average postoperative stay was 2.6 days (range, 1-8 days). No complications developed. The average follow-up was 35.13 months (range, 4-86 months). The freedom from any subsequent intervention was 50% at 10.5 months. The average number of endovascular procedures per patient during follow-up was 4.6. Ten patients had required access surgery during follow-up. Secondary patency was 100%. The median patient survival was 69.3 months. CONCLUSIONS Symptomatic hemodialysis patients with threatened vascular access caused by subclavian vein stenosis at the thoracic outlet were safely and successfully treated with first rib resection, followed by endovascular techniques. The procedure resulted in no morbidity and preserved dialysis access function in all patients during follow-up. Our experience has confirmed that excellent secondary patency and long-term clinical success can be obtained with regular follow-up, although with multiple secondary interventions. The median survival of 69 months after the procedure suggests it is worthwhile to expend this effort to maintain the hemodialysis access function of these patients.
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Affiliation(s)
- Pablo V Uceda
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex
| | - Robert W Feldtman
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Tex
| | - Samuel S Ahn
- DFW Vascular Group, Dallas, Tex; Department of Surgery, Methodist Dallas Medical Center, Dallas, Tex; Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, Tex.
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Karaolanis G, Antonopoulos CN, Koutsias SG, Giosdekos A, Metaxas EK, Tzimas P, de Borst GJ, Geroulakos G. A systematic review and meta-analysis for the management of Paget-Schroetter syndrome. J Vasc Surg Venous Lymphat Disord 2021; 9:801-810.e5. [PMID: 33540134 DOI: 10.1016/j.jvsv.2021.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There is currently no general agreement on the optimal treatment of Paget-Schroetter syndrome. Most centers have advocated an interventional approach that is based on the results of small institutional series. The purpose of our meta-analysis was to focus on the safety and efficacy of thrombolysis or anticoagulation with decompression therapy. A detailed description of the epidemiologic, etiologic, and clinical characteristics, along with radiologic findings and treatment option details, was also performed. METHODS The current meta-analysis was conducted using the PRISMA guidelines. Studies reporting on spontaneous thrombosis or thrombosis after strenuous activities of axillary-subclavian vein were considered eligible. Analyses of all retrospective studies were conducted, and pooled proportions with 95% confidence intervals of outcome rates were calculated. RESULTS Twenty-five studies with 1511 patients were identified. Among these patients, 1177 (77.9%) had thrombolysis, 658 (43.5%) had anticoagulation, and 1293 (85.6%) patients had decompression therapy of the thoracic outlet. Complete thrombus resolution was estimated at 78.11% of the patients after thrombolysis, and the respective pooled proportion for partial resolution of thrombus was 23.72%. Despite thrombolytic therapy, 212 patients underwent additional balloon angioplasty for residual stenosis, although only 36 stents were implanted. After anticoagulation, a total of 40.70% of the patients had complete thrombus resolution, whereas partial resolution was occurred in 29.13% of the patients. During follow-up, a total of 51.75% of the patients with any initial treatment modality had no remaining thrombus, and 84.87% of these patients were free of symptoms. We also estimated that 76.88% of the patients had a Disabilities of the Arm, Shoulder and Hand score of <20, indicating no or mild symptoms after treatment. A subgroup meta-analysis with 20 studies and 1309 patients, showed significantly improved vein patency and symptom resolution in patients who had first rib resection with or without venoplasty, compared with those who had only thrombolysis. CONCLUSIONS Although no randomized controlled data are available, our analysis strongly suggested higher rates of thrombus and symptoms resolution with thrombolysis, followed by first rib resection. A prospective randomized trial comparing anticoagulants with thrombolysis and decompression of thoracic outlet is required.
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Affiliation(s)
- Georgios Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece.
| | - Constantine N Antonopoulos
- Cardiothoracic and Vascular Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece; Department of Vascular Surgery, Athens University Medical School, Athens, Greece
| | - Stylianos G Koutsias
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Alexandros Giosdekos
- Department of Vascular Surgery, Athens University Medical School, Athens, Greece
| | | | - Petros Tzimas
- Department of Anesthesiology, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Gert J de Borst
- Department of Vascular Surgery, UMC, Utrecht, The Netherlands
| | - George Geroulakos
- Department of Vascular Surgery, Athens University Medical School, Athens, Greece
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 270] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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17
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Pesser N, Bode A, Goeteyn J, Hendriks J, van Nuenen BFL, van Sambeek MRHM, Teijink JAW. Same Admission Hybrid Treatment of Primary Upper Extremity Deep Venous Thrombosis with Thrombolysis, Transaxillary Thoracic Outlet Decompression, and Immediate Endovascular Evaluation. Ann Vasc Surg 2020; 71:249-256. [PMID: 32795648 DOI: 10.1016/j.avsg.2020.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multiple algorithms exist for treating acute primary upper extremity deep venous thrombosis (pUEDVT) caused by venous thoracic outlet syndrome (VTOS). In this case series, we present the results of our dedicated same admission treatment algorithm. METHODS All patients between January 2015 and December 2019 with an established acute upper extremity deep venous thrombosis (symptoms <14 days) caused by VTOS were treated according to an algorithm consisting of same admission thrombolysis, transaxillary thoracic outlet decompression (TA-TOD) with extensive venolysis, and venography. If a residual stenosis of the subclavian vein was identified on venography, including by means of low-pressure diagnostic balloon inflation, correction by percutaneous transluminal angioplasty (PTA) was performed. The thoracic outlet syndrome disability scale, the Dutch language version of the disabilities of the arm, shoulder, and hand, and the VEINES-quality of life (VEINES-QOL/VEINES-symptoms) questionnaires were collected during follow-up. RESULTS In total, 10 patients were treated for acute pUEDVT. After successful thrombolysis (100%) and TA-TOD, immediate venography showed residual stenosis of the subclavian vein in 8 of 10 patients (80%). Low-pressure dilatation of a balloon suited to the geometry of the axillosubclavian vein showed significant tapering in all cases (10/10) after which a formal venous PTA was performed. No stents were used. Mean time to discharge was 6.4 days. All patients were free of symptoms at a mean follow-up period of 34.4 months. Eight of the 10 patients completed follow-up questionnaires and reported a mean thoracic outlet syndrome disability scale of 0.6, mean disabilities of the arm, shoulder, and hand score of 4.2, and a median VEINES-Symptoms of 55.23 (IQR, 12.13), and VEINES-QOL of 55.29 (IQR, 15.42). CONCLUSIONS A same admission treatment algorithm for acute pUEDVT in patients with VTOS including thrombolysis, TA-TOD with extensive venolysis, and immediate venography with PTA is effective with promising intermediate results.
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Affiliation(s)
- Niels Pesser
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Aron Bode
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jens Goeteyn
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Joris Hendriks
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Biomedical Technology, University of Technology Eindhoven, Eindhoven, The Netherlands
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
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Fairman AS, Fairman RM, Foley PJ, Etkin Y, Jackson OA, Jackson BM. Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome? Ann Vasc Surg 2020; 69:217-223. [PMID: 32497616 DOI: 10.1016/j.avsg.2020.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/26/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. METHODS Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. RESULTS Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. CONCLUSIONS This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.
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Affiliation(s)
- Alexander S Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Ronald M Fairman
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul J Foley
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | - Benjamin M Jackson
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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Gu G, Liu J, Lv Y, Huang H, Li F, Chen M, Chen Y, Shao J, Liu B, Liu C, Zhang X, Zheng Y. Costoclavicular ligament as a novel cause of venous thoracic outlet syndrome: from anatomic study to clinical application. Surg Radiol Anat 2020; 42:865-870. [PMID: 32424683 DOI: 10.1007/s00276-020-02479-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/22/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Venous thoracic outlet syndrome (VTOS) is a compressive disorder of subclavian vein (SCV); we aimed to investigate the role of costoclavicular ligament (CCL) in the pathogenesis of VTOS. METHODS A cadaver study was carried out to investigate the presence and morphology of CCL in thoracic outlet regions, as well as its relationship with the SCV. Six formalin-fixed adult cadavers were included, generating 12 dissections of costoclavicular regions (two sides per cadaver). Once CCL was identified, observation and measurement were made of its morphology and dimensions, and its relationship with SCV was studied. To take a step further, a clinical VTOS case was reported to prove the anatomical findings. RESULTS Two out of twelve costoclavicular regions (2/12, 16.7%) were found to possess CCLs. Both ligaments were located in the left side of two male cadavers and were closely attached to the lateral aspect of sternoclavicular joint capsules. The lateral fibers of the ligament proceed in a superolateral-to-inferomedial manner, while the medial fibers proceed more vertically. Both ligaments were tightly adherent to the SCV, causing significant compression on the vein. In the clinical case, multiple bunches of CCLs were found to compress the SCV tightly intraoperatively. After removing the ligaments, the patient's symptom kept relief during a follow-up period of 2 years. CONCLUSION Our study demonstrated that CCL could be a novel cause of VTOS by severe compression of SCV. Patients diagnosed with this etiology could get less invasive surgical treatment by simply removing the ligament.
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Affiliation(s)
- Guangchao Gu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China.,Tsinghua University School of Medicine, Medical Science Building A, Room 117, Haidian District, Beijing, 100084, China
| | - Jinping Liu
- Tsinghua University School of Medicine, Medical Science Building A, Room 117, Haidian District, Beijing, 100084, China
| | - Yanze Lv
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Hui Huang
- Tsinghua University School of Medicine, Medical Science Building A, Room 117, Haidian District, Beijing, 100084, China
| | - Fangda Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Mengyin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Xiaodong Zhang
- Tsinghua University School of Medicine, Medical Science Building A, Room 117, Haidian District, Beijing, 100084, China.
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China.
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Zurkiya O, Ganguli S, Kalva SP, Chung JH, Shah LM, Majdalany BS, Bykowski J, Carter BW, Chandra A, Collins JD, Gunn AJ, Kendi AT, Khaja MS, Liebeskind DS, Maldonado F, Obara P, Sutphin PD, Tong BC, Vijay K, Corey AS, Kanne JP, Dill KE. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. J Am Coll Radiol 2020; 17:S323-S334. [PMID: 32370976 DOI: 10.1016/j.jacr.2020.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
Thoracic outlet syndrome (TOS) is the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. Compression of each of these structures results in characteristic symptoms divided into three variants: neurogenic TOS, venous TOS, and arterial TOS, each arising from the specific structure that is compressed. The constellation of symptoms in each patient may vary, and patients may have more than one symptom simultaneously. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes is important in choosing and interpreting radiological imaging performed to help diagnose TOS and plan for intervention. This publication has separated imaging appropriateness based on neurogenic, venous, or arterial symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, new symptoms may arise altering the need for specific imaging as compared to preoperative evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Omar Zurkiya
- Research Author, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | | | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | | | | | - Brett W Carter
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ankur Chandra
- Scripps Green Hospital, La Jolla, California; Society for Vascular Surgery
| | | | - Andrew J Gunn
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California; American Academy of Neurology
| | - Fabien Maldonado
- Vanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians
| | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | | | - Betty C Tong
- Duke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons
| | | | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Karin E Dill
- Specialty Chair, UMass Memorial Medical Center, Worcester, Massachusetts
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Cai TY, Rajendran S, Saha P, Dubenec S. Paget-Schroetter syndrome: A contemporary review of the controversies in management. Phlebology 2020; 35:461-471. [DOI: 10.1177/0268355519898920] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome. Materials and methods We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome. Results There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed. Conclusions Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.
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Affiliation(s)
- Tommy Y Cai
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Saissan Rajendran
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Prakash Saha
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Academic Department of Vascular Surgery, St Thomas’ Hospital, King’s College London, London, UK
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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22
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False-negative upper extremity ultrasound in the initial evaluation of patients with suspected subclavian vein thrombosis due to thoracic outlet syndrome (Paget-Schroetter syndrome). J Vasc Surg Venous Lymphat Disord 2020; 8:118-126. [DOI: 10.1016/j.jvsv.2019.08.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/11/2019] [Indexed: 11/18/2022]
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23
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Bozzay JD, Walker PF, Ronaldi AE, Patel JA, Koelling EE, White PW, Rasmussen TE, Golarz SR, White JM. Infraclavicular Thoracic Outlet Decompression Compared to Supraclavicular Thoracic Outlet Decompression for the Management of Venous Thoracic Outlet Syndrome. Ann Vasc Surg 2019; 65:90-99. [PMID: 31678546 DOI: 10.1016/j.avsg.2019.10.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/28/2019] [Accepted: 10/22/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The treatment of venous thoracic outlet syndrome (VTOS) requires surgical decompression often combined with catheter-directed thrombolysis and venoplasty. Surgical options include transaxillary, supraclavicular, or infraclavicular approaches to first rib resection. The optimal method, however, has yet to be defined. The purpose of this study is to compare the outcomes of patients who underwent infraclavicular versus supraclavicular surgical decompression for VTOS. METHODS A retrospective review of patients who underwent surgical management for VTOS from December 2010 to November 2017 was performed. During the study period, supraclavicular and infraclavicular approaches were chosen according to surgeon preference. Patient demographics, pre- and postdecompression interventions, perioperative outcomes for each group of patients were analyzed. RESULTS Thirty patients underwent surgical management of VTOS, of which 15 (50%) underwent infraclavicular decompression and 15 (50%) supraclavicular decompression. The mean age of patients was 32.1 ± 13.6 years and 80% were male. Twenty-six patients (86.7%) presented with thrombotic VTOS. Acute axillosubclavian vein thrombosis was present in 20 (76.9%) of these patients, 10 patients in each group. Subacute or chronic thrombosis was encountered in the remaining 6 (23%) patients, 2 patients in the infraclavicular group and 4 patients in the supraclavicular group. Preoperative thrombolysis was utilized in 7 (46.7%) and 6 (40%) patients in the infraclavicular and supraclavicular groups, respectively (P = 1.00). Patients without postdecompression venography were removed from analysis and included 1 patient in the infraclavicular group and 5 patients in the supraclavicular group. Initial postdecompression venogram, prior to any endovascular intervention, demonstrated a residual axillosubclavian vein stenosis of greater than 50% in 6 (42.9%) patients in the infraclavicular decompression group and 7 (70%) patients in the supraclavicular decompression group (P = 0.24). Crossing the stenosis after surgical decompression was more easily accomplished in the infraclavicular group, 14 (100%) versus 5 (50%), (P = 0.01). Following endovascular venoplasty, calculated residual stenosis greater than 50% was found in 0 (0%) and 3 (30%) patients in the infraclavicular and supraclavicular approaches, respectively (P = 0.047). Infraclavicular thoracic outlet decompression was associated with fewer patients with postoperative symptoms, 0 of 15 (0%) versus 8 of 15 (53.3%), (P = 0.0022), and infraclavicular thoracic outlet decompression demonstrated improved patency, 15 of 15 (100%) versus 8 of 15 (53.3%), (P = 0.028) at a mean combined follow-up of 8.47 ± 10.8 months. CONCLUSIONS Infraclavicular thoracic outlet decompression for the surgical management of VTOS was associated with fewer postoperative symptoms and improved axillosubclavian vein patency compared to the supraclavicular approach. Prospective analysis is warranted to determine long-term outcomes following infraclavicular decompression.
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Affiliation(s)
- Joseph D Bozzay
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Patrick F Walker
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Alley E Ronaldi
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jigarkumar A Patel
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Erin E Koelling
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Paul W White
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Todd E Rasmussen
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Scott R Golarz
- Department of Surgery, Temple Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA
| | - Joseph M White
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD.
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Liu Y, Wu Z, Huang B, Yang Y, Zhao J, Ma Y. Venous thoracic outlet syndrome secondary to arterial stent implantation: A case report. Medicine (Baltimore) 2019; 98:e17829. [PMID: 31764776 PMCID: PMC6882654 DOI: 10.1097/md.0000000000017829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Venous thoracic outlet syndrome (VTOS) secondary to subclavian arterial stent implantation is extremely rare. Here, we firstly report this disease and the endovascular intervention using covered-stents. PATIENT CONCERNS An 80-year-old man who had received an acceptable stent implantation for the treatment of a right subclavian arteriovenous malformation (AVM), presented with a gradually increasing swelling and pain in his right upper extremity. DIAGNOSIS The patient was diagnosed with right VTOS and recurrent subclavian AVM following ultrasonography and computed tomographic angiography. INTERVENTIONS We positioned a covered-stent in the subclavian artery to block the feeding arteries and successfully embolized the remaining branches with coils. Next, we performed successful dilation 3 times, followed by the positioning of another covered-stent in the right subclavian vein. OUTCOMES The patient was free of all symptoms and the imaging procedures confirmed an acceptable thrombosis of the AVM with patent stents in the right subclavian artery and vein during the 6-month follow-up. LESSONS Venous stent implantation is an alternative to treat VTOS caused by subclavian arterial stents and it is essential to pay more attention to the incidence of VTOS following arterial stent implantation in the subclavian artery.
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Affiliation(s)
- Yang Liu
- Department of Vascular Surgery, West China Hospital
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Zhoupeng Wu
- Department of Vascular Surgery, West China Hospital
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital
| | - Yukui Ma
- Department of Vascular Surgery, West China Hospital
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Outcomes of venous bypass combined with thoracic outlet decompression for treatment of upper extremity central venous occlusion. J Vasc Surg Venous Lymphat Disord 2019; 7:660-664. [DOI: 10.1016/j.jvsv.2019.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 03/28/2019] [Indexed: 11/21/2022]
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Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB, Brunk AJ, Eng MR, Orhurhu V, Cornett EM, Kaye AD. Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain Ther 2019; 8:5-18. [PMID: 31037504 PMCID: PMC6514035 DOI: 10.1007/s40122-019-0124-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 12/22/2022] Open
Abstract
Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Practitioners must consider the pathology of thoracic outlet syndrome in their differential diagnosis for shoulder and upper extremity pain symptoms so that patients are directed appropriately to timely therapeutic interventions. Patients with a definitive etiology who have failed conservative management are ideal candidates for surgical correction. This manuscript will discuss thoracic outlet syndrome, occurrence, physical presentation, clinical implications, diagnosis, and management.
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Affiliation(s)
- Mark R Jones
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA.
| | - Amit Prabhakar
- Division of Critical Care, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA
| | - Jeremy B Green
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Julia B Kendrick
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Andrew J Brunk
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Matthew R Eng
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
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Thiyagarajah K, Ellingwood L, Endres K, Hegazi A, Radford J, Iansavitchene A, Lazo-Langner A. Post-thrombotic syndrome and recurrent thromboembolism in patients with upper extremity deep vein thrombosis: A systematic review and meta-analysis. Thromb Res 2019; 174:34-39. [DOI: 10.1016/j.thromres.2018.12.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/13/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
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Wooster M, Fernandez B, Summers KL, Illig KA. Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients. J Vasc Surg Venous Lymphat Disord 2019; 7:106-112.e3. [DOI: 10.1016/j.jvsv.2018.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 07/31/2018] [Indexed: 10/27/2022]
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Archie MM, Rollo JC, Gelabert HA. Surgical Missteps in the Management of Venous Thoracic Outlet Syndrome Which Lead to Reoperation. Ann Vasc Surg 2018; 49:261-267. [DOI: 10.1016/j.avsg.2018.01.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 11/20/2017] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
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Samoila G, Twine CP, Williams IM. The infraclavicular approach for Paget-Schroetter syndrome. Ann R Coll Surg Engl 2018; 100:83-91. [PMID: 29388461 PMCID: PMC5838687 DOI: 10.1308/rcsann.2017.0154] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Paget-Schroetter syndrome is a rare effort thrombosis of the axillary-subclavian vein, mainly occurring in young male patients. Current management involves immediate catheter directed thrombolysis, followed by surgical decompression of the subclavian vein. This has been invariably performed using a transaxillary or supraclavicular approach. However, the subclavian vein crosses the first rib anteriorly just behind the manubrium and can also be accessed via an infraclavicular incision. Methods MEDLINE® and Embase™ were searched for all studies on outcomes in patients undergoing infraclavicular first rib resection for treatment of Paget-Schroetter syndrome. Measured outcomes included freedom from reintervention, secondary patency and symptom resolution. Studies on neurogenic, arterial and iatrogenic venous thoracic outlet syndrome were not included. Findings Six studies (involving 268 patients) were eligible. The overall secondary venous patency rate was 98.5%. There was freedom from reintervention in 89.9% of cases and among those patients with reocclusion, 84.0% had chronic thrombosis (symptom duration >14 days), with 76.2% having a venous segment stenosis of >2cm. Only 3 of the 27 patients remained occluded despite reintervention. The infraclavicular approach provides excellent exposure to the subclavian vein and allows reconstruction when required. Moreover, this approach enables complete resection of the extrinsic compression that precipitated the initial thrombotic event, with excellent long-term patency rates. In conclusion, the infraclavicular route may have significant advantages compared with the transaxillary or supraclavicular approaches for successful and durable treatment of Paget-Schroetter syndrome.
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Affiliation(s)
- G Samoila
- Cardiff and Vale University Health Board , UK
| | - C P Twine
- Aneurin Bevan University Health Board , UK
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31
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Grant JD, Woller S, Lee E, Kee S, Liu D, Lohan D, Elliott CG, Stevens S. Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost 2017; 108:1097-108. [DOI: 10.1160/th12-05-0352] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 08/30/2012] [Indexed: 11/05/2022]
Abstract
SummaryUpper extremity deep-vein thrombosis (UEDVT) is common and can cause important complications, including pulmonary embolism and post-thrombotic syndrome. An increase in the use of central venous catheters, particularly peripherally inserted central catheters has been associated with an increasing rate of disease. Accurate diagnosis is essential to guide management, but there are limitations to the available evidence for available diagnostic tests. Anticoagulation is the mainstay of therapy, but interventional treatments may be considered in select situations. The risk of UEDVT may be reduced by more careful selection of patients who receive central venous catheters and by use of smaller catheters. Herein we review the diagnosis, management and prevention of UEDVT. Due to paucity of research, some principles are drawn from studies of lower extremity DVT. We present a practical approach to diagnosing the patient with suspected deep-vein thrombosis of the upper extremity.
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Safety and Efficacy of Catheter-Directed Therapies as a Supplement to Surgical Decompression in Venous Thoracic Outlet Syndrome. AJR Am J Roentgenol 2017; 210:W80-W85. [PMID: 29112470 DOI: 10.2214/ajr.16.17730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the role of endovascular therapy in the management of venous thoracic outlet syndrome (TOS), with an emphasis on its role after surgical decompression. MATERIALS AND METHODS This single-center retrospective review identified all patients who underwent conventional contrast-enhanced venography as a component of the imaging evaluation of clinically suspected venous TOS from January 2004 through September 2015. Eighty-one patients were identified, with a mean (± SD) age of 33 ± 12 years, of whom 59% (48/81) were women. After imaging confirmation of venous TOS, a standardized treatment protocol combining surgical and endovascular intervention was used for management. RESULTS Of the 81 patients included in the study, 73 (90%) had angiographic evidence of venous TOS; 41 of these 73 patients (56%) underwent endovascular venous intervention (e.g., thrombolysis or angioplasty before surgical) decompression. A total of 67 patients (67/73; 92%) with venous TOS underwent surgical decompression, with 56 of these (56/73; 77%) undergoing postoperative venography. Of these 56 patients who underwent postoperative venography, 48 (86%) required venoplasty, four had normal-appearing subclavian veins (7%) and had no intervention, and four of 48 (8%) had chronic total venous occlusions that could not be recanalized. Only four of the 48 of the patients (8%) who underwent postdecompression venoplasty required subsequent repeat venography and intervention for management of persistent or recurrent symptoms, whereas all others (44/48; 92%) remained symptom free on clinical follow-up. No complications were identified that were related to the endovascular interventions. CONCLUSION Combining venography and endovascular venous intervention with surgical decompression in managing patients with clinically suspected venous TOS is safe and effective. Postdecompression venoplasty appears to be highly effective, with a low rate of symptom recurrence.
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Vazquez FJ, Paulin P, Poodts D, Gándara E. Preferred Management of Primary Deep Arm Vein Thrombosis. Eur J Vasc Endovasc Surg 2017; 53:744-751. [PMID: 28342731 DOI: 10.1016/j.ejvs.2016.11.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 11/14/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Given its rarity, the management of primary upper extremity deep vein thrombosis is controversial. Although anticoagulation alone is commonly advocated for its treatment, it is unclear if this will reduce the risk of developing post-thrombotic syndrome (PTS). The aim of this "Evidence Driven" Clinical Scenario is to evaluate whether more aggressive treatments (including catheter directed thrombolysis or surgery) might help reduce the risk of PTS or recurrent venous thromboembolism in patients with primary upper extremity deep vein thrombosis (DVT). METHODS An electronic systematic review of Ovid MEDLINE and Embase was conducted. Randomised controlled trials and observational studies were eligible. The primary outcome was PTS. RESULTS The initial search identified 146 articles, and 36 more were identified during a secondary search. In total, 25 studies, reporting the outcome of 1271 patients, were included. None of the studies included was a randomised controlled trial and the large majority of studies were retrospective cohorts. The use of anticoagulation alone was associated with a significant risk of PTS. In patients treated with surgery with or without thrombolysis the incidence of PTS was significantly reduced. CONCLUSION Current evidence, albeit with some methodological limitations, suggests that anticoagulation may not be sufficient to prevent PTS in patients with primary upper extremity DVT and that surgery with or without thrombolysis to repair the anatomical defects is needed.
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Affiliation(s)
- F J Vazquez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - P Paulin
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - D Poodts
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - E Gándara
- Department of Medicine, University of Ottawa-Ottawa Hospital, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Internal Medicine, Hospital Privado de Comunidad, Mar del Plata, Argentina.
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Ferrante MA, Ferrante ND. The thoracic outlet syndromes: Part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve 2017; 56:663-673. [PMID: 28006856 DOI: 10.1002/mus.25535] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 01/08/2023]
Abstract
The thoracic outlet syndromes (TOSs) are a group of etiologically and clinically distinct disorders with 1 feature in common: compression of 1 or more neurovascular elements as they traverse the thoracic outlet. The medical literature reflects 5 TOSs: arterial; venous; traumatic neurovascular; true neurogenic; and disputed. Of these, the first 4 demonstrate all of the features expected of a syndrome, whereas disputed TOS does not, causing many experts to doubt its existence altogether. Thus, some categorize disputed TOSs as cervicoscapular pain syndrome rather than as a type of TOS. To better understand these disorders, their distinctions, and the reasoning underlying the categorical change of disputed TOS from a form of TOS to a cervicoscapular pain syndrome, a thorough understanding of the pertinent anatomy, pathology, pathophysiology, and electrodiagnostic manifestations of these pathophysiologies is required. This review of the TOSs is provided in 2 parts. In part 1 we covered general information pertinent to all 5 TOSs and reviewed true neurogenic TOS in detail. In part 2, we review the arterial, venous, traumatic neurovascular, and disputed forms of TOS. Muscle Nerve 56: 663-673, 2017.
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Affiliation(s)
- Mark A Ferrante
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Neurophysiology Division, Department of Neurology, Veterans Administration Medical Center, Memphis, Tennessee, USA
| | - Nicole D Ferrante
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
Spontaneous thrombosis of the axillary and subclavian venous segments in young, healthy adults (effort thrombosis or Paget-Schroetter syndrome) is a rare but potentially disabling affliction. The diagnosis should be suspected in any young patient presenting with unilateral arm swelling. Typically, the dominant arm is affected, and frequent, repetitive arm use is a common component of the patients' history. Although the diagnosis can often be confirmed with a venous duplex evaluation, the central location of the venous abnormality occasionally mandates cross-sectional imaging or contrast venography to confirm the diagnosis. The underlying pathophysiology of this disorder is felt to be repetitive venous trauma owing to arm motion in the narrow anatomic space between the clavicle and first rib. The treatment of Paget-Schroetter syndrome is controversial and varies according to individual, institutional, and regional preferences. In general, the trend is toward more aggressive endovascular treatment. Prompt anticoagulation is generally accepted as the minimal treatment offered. Catheter-directed thrombolysis has also acquired a prominent role in reestablishing venous patency. The importance of relieving the anatomic compression of the subclavian vein by first rib resection remains controversial, with some experts advocating surgical intervention in all affected patients, whereas others perform this procedure selectively in cases of persistent venous stenosis or ongoing symptoms. Angioplasty with or without stenting is generally discouraged in the absence of anatomic decompression but may play an adjunctive role in patients undergoing first rib resection.
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Affiliation(s)
- Gregory J. Landry
- *Division of Vascular Surgery, Oregon Health & Science University, Portland, OR
| | - Timothy K. Liem
- *Division of Vascular Surgery, Oregon Health & Science University, Portland, OR
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Edo Fleta G, Torres Blanco Á, Gómez Palonés F, Ortiz Monzón E. Combined non-surgical treatment for Paget-Schröetter syndrome: a case report. J Med Case Rep 2016; 10:171. [PMID: 27286869 PMCID: PMC4902955 DOI: 10.1186/s13256-016-0940-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Paget-Schröetter syndrome is an uncommon form of venous thrombosis, which is related to thoracic outlet syndrome. Axillary-subclavian vein thrombosis typically presents in healthy young adults. We present this case of particular interest because it indicates that a combined treatment involving thrombolysis, anticoagulation therapy, rehabilitation, and elastic compression sleeves can be a valid non-surgical alternative for some patients with Paget-Schröetter syndrome. CASE PRESENTATION This report describes a case of a 38-year-old white woman, a swimmer, who presented with a sudden episode of swelling and pain in her right upper extremity. After duplex ultrasound diagnosis of venous thrombosis, computed tomography (CT) showed extrinsic compression of the vessel. Catheter-directed thrombolysis was performed in the first 24 hours, followed by anticoagulant therapy with bemiparin at a dose of 7500 IU/24 hours for the first week, and then reduced to 3500 IU/24 hours for the next 3 months. After treatment there was restoration of her venous flow and she returned to work 2 weeks later. Anticoagulant treatment was continued for 3 months; decompression surgery was not performed. At 6 months she was asymptomatic. CONCLUSION Combined treatment involving thrombolysis, anticoagulant therapy, rehabilitation, and elastic compression sleeves may be a valid non-surgical alternative for a selected subset of patients with Paget-Schröetter syndrome.
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Affiliation(s)
- Gemma Edo Fleta
- Department of Angiology, Vascular and Endovascular Surgery, Hospital Universitario Doctor Peset, Avenida de Gaspar Aguilar, 90, 46017, Valencia, Spain.
| | - Álvaro Torres Blanco
- Department of Angiology, Vascular and Endovascular Surgery, Hospital Universitario Doctor Peset, Avenida de Gaspar Aguilar, 90, 46017, Valencia, Spain
| | - Francisco Gómez Palonés
- Department of Angiology, Vascular and Endovascular Surgery, Hospital Universitario Doctor Peset, Avenida de Gaspar Aguilar, 90, 46017, Valencia, Spain
| | - Eduardo Ortiz Monzón
- Department of Angiology, Vascular and Endovascular Surgery, Hospital Universitario Doctor Peset, Avenida de Gaspar Aguilar, 90, 46017, Valencia, Spain
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Hussain MA, Aljabri B, Al-Omran M. Vascular Thoracic Outlet Syndrome. Semin Thorac Cardiovasc Surg 2016; 28:151-7. [DOI: 10.1053/j.semtcvs.2015.10.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2015] [Indexed: 11/11/2022]
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Siracuse JJ, Johnston PC, Jones DW, Gill HL, Connolly PH, Meltzer AJ, Schneider DB. Infraclavicular first rib resection for the treatment of acute venous thoracic outlet syndrome. J Vasc Surg Venous Lymphat Disord 2015; 3:397-400. [DOI: 10.1016/j.jvsv.2015.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
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Mallios A, Taubman K, Claiborne P, Blebea J. Subclavian Vein Stent Fracture and Venous Motion. Ann Vasc Surg 2015; 29:1451.e1-4. [DOI: 10.1016/j.avsg.2015.04.064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 03/15/2015] [Accepted: 04/05/2015] [Indexed: 11/26/2022]
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Acute Paget–Schroetter Syndrome: Does the First Rib Routinely Need to Be Removed after Thrombolysis? Ann Vasc Surg 2015; 29:1073-7. [DOI: 10.1016/j.avsg.2015.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/07/2015] [Accepted: 02/18/2015] [Indexed: 11/18/2022]
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Shi Y, Zhu M, Cheng J, Zhang J, Ni Z. Venous stenosis in chronic dialysis patients with a well-functioning arteriovenous fistula. Vascular 2015; 24:25-30. [PMID: 25725216 DOI: 10.1177/1708538115575649] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose It is not clear whether patient who is dialyzing with a well-functioning vascular access may appear venous stenosis. The aim is to see the prevalence of central or other vein stenoses/occlusions in patients with asymptomatic, normal functioning fistulas. Methods A total of 54 patients met the inclusion criteria. We performed angiography examinations for these patients and reviewed venography of the superficial and deep venous systems. Results Among these patients, 21 (39%) were detected positive cases by the angiography, the remainder was negative cases. Thirteen of 54 (24%) had mild central venous stenosis (stenosis <50% diameter with or without collateral branch), 7/54 (13%) had upper arm vein system occlusion or stenosis, another one had anastomotic stenosis. There were no differences in fistula flow dynamics between those with venous abnormalities and those without such as blood flow rate, venous pressures, brachial arterial velocity, and brachial arterial flow rate. We also observed no significant differences in other variables between these two groups (including BMI, hemoglobin, albumin, gender, primary disease, URR, spKt/V P > 0.05). Conclusion The frequency of venous lesion is not low in hemodialysis patients with a well-functioning AVF. To value the impact of these abnormalities on access, prognosis needs longer time follow-up.
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Affiliation(s)
- Yaxue Shi
- Vascular Surgery Department, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Mingli Zhu
- Renal Department, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jiejun Cheng
- Radiology Department, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jiwei Zhang
- Vascular Surgery Department, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhaohui Ni
- Renal Department, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Hawkins AT, Schaumeier MJ, Smith AD, de Vos MS, Ho KJ, Semel ME, Nguyen LL. Concurrent venography during first rib resection and scalenectomy for venous thoracic outlet syndrome is safe and efficient. J Vasc Surg Venous Lymphat Disord 2014; 3:290-4. [PMID: 26992308 DOI: 10.1016/j.jvsv.2014.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography. METHODS Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications. RESULTS Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17-52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis. CONCLUSIONS FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms.
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Affiliation(s)
- Alexander T Hawkins
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Maria J Schaumeier
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Ann D Smith
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Marit S de Vos
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, Mass
| | - Karen J Ho
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Marcus E Semel
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular & Endovascular Surgery, Brigham & Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Abstract
BACKGROUND Thoracic outlet syndrome (TOS) is one of the most controversial diagnoses in clinical medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence-based management is lacking. This is the first update of a review first published in 2010. OBJECTIVES To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of TOS a minimum of six months after the intervention. SEARCH METHODS On 23 June 2014 we searched the Cochrane Neuromuscular Disease Group Trials Specialized Register, CENTRAL, The Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL Plus and AMED. We also searched reference lists of the identified trials. SELECTION CRITERIA We selected randomized or quasi-randomized studies involving participants with the diagnosis of TOS of any type (neurogenic, vascular, and 'disputed'), without limitations as to language of publication.We accepted studies that examined any intervention aimed at treating TOS.The primary outcome measure was change in pain rating, measured on a validated visual analog or similar scale at least six months after the intervention.The secondary outcomes were change in muscle strength, disability, experiences of paresthesias (numbness and tingling sensations), and adverse effects of the interventions. DATA COLLECTION AND ANALYSIS Three authors independently selected the trials to be included and extracted data. Authors rated included studies for risk of bias, according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. We identified one study comparing natural progression with an active intervention. We found three randomized controlled trials (RCTs), but only two of them had a follow-up of six months or more, which was the minimum required follow-up for inclusion in the review. The first trial that met our requirements involved 55 participants with the 'disputed type' of TOS and compared transaxillary first rib resection (TFRR) with supraclavicular neuroplasty of the brachial plexus (SNBP). The trial had a high risk of bias. TFRR decreased pain more than SNBP. There were no adverse effects in either group. The second trial that met these requirements analyzed 37 people with TOS of any type, comparing treatment with a botulinum toxin (BTX) injection into the scalene muscles with a saline placebo injection. This trial had a low risk of bias. There was no significant effect of treatment with the BTX injection over placebo in terms of pain relief or improvements in disability, but it did significantly improve paresthesias at six months' follow-up. There were no adverse events of the BTX treatment above saline injection. AUTHORS' CONCLUSIONS This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty, but no randomized evidence that either is better than no treatment. There is moderate evidence to suggest that treatment with BTX injections yielded no great improvements over placebo injections of saline. There is no evidence from RCTs for the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures, and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.
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Affiliation(s)
- Bo Povlsen
- London Bridge HospitalLondon Hand Clinic27 Tooley StreetLondonUKSE1 2PR
| | - Thomas Hansson
- University HospitalPlastic Surgery, Hand Surgery and BurnsS‐581 85LinkopingSweden
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De Caridi G, Massara M, Greco M, Villari S, Squillaci D, Spinelli F. Hybrid management of Paget-Schroetter syndrome due to thoracic outlet syndrome. Gen Thorac Cardiovasc Surg 2014; 64:109-12. [PMID: 25005008 DOI: 10.1007/s11748-014-0445-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 06/20/2014] [Indexed: 11/28/2022]
Abstract
Paget-Schroetter syndrome due to thoracic outlet syndrome is a rare but potentially disabling condition that generally affects young patients otherwise healthy. The prompt diagnosis and treatment of Paget-Schroetter syndrome is necessary to avoid major morbidity and long-term disability. The more modern treatment paradigm reported in the current literature consists of hybrid procedures with surgical decompression of the thoracic outlet and endovascular techniques to potentially improve long-term vein patency. However, there seems to be no consensus in the literature with regard to the timing and precise nature of active management, and there is presently no agreed protocol for the optimum management of Paget-Schroetter syndrome. Controversy exists partly because no randomised controlled studies are present in literature. We present a case of Paget-Schroetter syndrome due to thoracic outlet syndrome in a young male patient submitted to a multimodal procedure.
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Affiliation(s)
- Giovanni De Caridi
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy.
- , Via Marina Arenile 57/a, 89135, Reggio Calabria, Italy.
| | - Mafalda Massara
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Michele Greco
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Simona Villari
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Domenico Squillaci
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
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Limited venoplasty and anticoagulation affords excellent results after first rib resection and scalenectomy for subacute Paget-Schroetter syndrome. J Vasc Surg Venous Lymphat Disord 2014; 2:297-302. [DOI: 10.1016/j.jvsv.2013.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/20/2013] [Accepted: 12/02/2013] [Indexed: 11/21/2022]
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Gelabert HA, Jabori S, Barleben A, Kiang S, O'Connell J, Jimenez JC, DeRubertis B, Rigberg D. Regrown First Rib in Patients with Recurrent Thoracic Outlet Syndrome. Ann Vasc Surg 2014; 28:933-8. [DOI: 10.1016/j.avsg.2014.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 01/15/2014] [Accepted: 01/15/2014] [Indexed: 11/30/2022]
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Wadhawan A, Laage Gaupp FM, Sista AK. Automatic implantable cardiac defibrillator implantation may precipitate effort-induced thrombosis in young athletes: a case report and literature review. Clin Imaging 2014; 38:510-514. [PMID: 24794202 DOI: 10.1016/j.clinimag.2014.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 03/18/2014] [Accepted: 03/25/2014] [Indexed: 11/30/2022]
Abstract
Upper extremity deep vein thrombosis (DVT) is a common finding after implantation of an automatic implantable cardiac defrillator (AICD). We describe the case of a patient who developed a left upper extremity DVT 4.5 months after implantation of an AICD and was found to have a lead-induced stenosis with possible underlying Paget-Schroetter syndrome (PSS) in the midbrachiocephalic vein on venography. While his symptoms resolved after the combination of pharmacomechanical thrombolysis, angioplasty, and anticoagulation, his long-term management is complicated by the presence of both PSS and lead-induced stenosis. Herein, we discuss his presentation, treatment, and future management options.
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Affiliation(s)
- Abhishek Wadhawan
- Government Medical College, Amritsar, India; Department of Radiology, Weill Cornell Medical College
| | - Fabian M Laage Gaupp
- Department of Radiology, Weill Cornell Medical College; Ludwig-Maximilians-University Munich, Germany
| | - Akhilesh K Sista
- Division of Interventional Radiology, Weill Cornell Medical College.
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48
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Tsekouras N, Comerota AJ. Current trends in the treatment of venous thoracic outlet syndrome: a comprehensive review. Interv Cardiol 2014. [DOI: 10.2217/ica.13.91] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Botas Velasco M, Calvín Álvarez P, Vaquero Lorenzo F, Álvarez Salgado A, Álvarez Fernández LJ. Síndrome de Paget-Schroetter. Cir Esp 2013; 91:392-3. [DOI: 10.1016/j.ciresp.2012.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Accepted: 02/14/2012] [Indexed: 10/27/2022]
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Klaassen Z, Sorenson E, Tubbs RS, Arya R, Meloy P, Shah R, Shirk S, Loukas M. Thoracic outlet syndrome: a neurological and vascular disorder. Clin Anat 2013; 27:724-32. [PMID: 23716186 DOI: 10.1002/ca.22271] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 04/29/2013] [Accepted: 04/22/2013] [Indexed: 11/06/2022]
Abstract
Thoracic outlet syndrome (TOS) is a condition arising from compression of the subclavian vessels and/or brachial plexus as the structures travel from the thoracic outlet to the axilla. Despite the significant pathology associated with TOS, there remains some general disagreement among experts on the specific anatomy, etiology, and pathophysiology of the condition, presumably because of the wide variation in symptoms that manifest in presenting patients, and because of lack of a definitive gold standard for diagnosis. Symptoms associated with TOS have traditionally been divided into vascular and neurogenic categories, a distinction based on the underlying structure(s) implicated. Of the two, neurogenic TOS (nTOS) is more common, and typically presents as compression of the brachial plexus; primarily, but not exclusively, involving its lower trunk. Vascular TOS (vTOS) usually involves compression of the vessel, most commonly the subclavian artery or vein, or is secondary to thrombus formation in the venous vasculature. Any anatomical anomaly in the thoracic outlet has the potential to predispose a patient to TOS. Common anomalies include variations in the insertion of the anterior scalene muscle (ASM) or scalenus minimus muscle, the presence of a cervical rib or of fibrous and muscular bands, variations in insertion of pectoralis minor, and the presence of neurovascular structures, which follow an atypical course. A common diagnostic technique for vTOS is duplex imaging, which has generally replaced more invasive angiographic techniques. In cases of suspected nTOS, electrophysiological nerve studies and ASM blocks provide guidance when screening for patients likely to benefit from surgical decompression of TOS. Surgeons generally agree that the transaxillary approach allows the greatest field of view for first rib excision to relieve compressed vessels. Alternatively, a supraclavicular approach is favored for scalenotomies when the ASM impinges on surrounding structures. A combined supraclavicular and infraclavicular approach is preferred when a larger field of view is required. The future of TOS management must emphasize the improvement of available diagnostic and treatment techniques, and the development of a consensus gold standard for diagnosis. Helical computed tomography offers a three-dimensional view of the thoracic outlet, and may be valuable in the detection of anatomical variations, which may predispose patients to TOS. This review summarizes the history of TOS, the pertinent clinical and anatomical presentations of TOS, and the commonly used diagnostic and treatment techniques for the condition.
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Affiliation(s)
- Zachary Klaassen
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
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