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Yin V, Udelsman BV, Kim AT, Wightman SC, Harano T, Rosenberg GM, Atay SM, Kim AW. Thrombolysis and Surgical Decompression for Venous Thoracic Outlet Syndrome. J Surg Res 2024; 303:134-140. [PMID: 39332077 DOI: 10.1016/j.jss.2024.08.023] [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: 12/04/2023] [Revised: 08/06/2024] [Accepted: 08/27/2024] [Indexed: 09/29/2024]
Abstract
INTRODUCTION Treatment for venous thoracic outlet syndrome (vTOS) includes thrombolysis followed by decompressive rib resection. Given the rarity of the disease, the goal of this study was to describe current practices in treatment of vTOS. METHODS All patients with diagnoses of subclavian vTOS who underwent rib resection in the 2018-2020 Nationwide Readmissions Database were included in this study. Patients were grouped based on number of days between thrombolysis and by number of hospitalizations: thrombolysis followed by surgery in the same hospitalization was considered "simultaneous" and in separate hospitalizations was "staged." RESULTS Five hundred ninety patients met the inclusion criteria. The average age was 34.1 ± 13.3 y, and 42.9% (253 of 590) were female. Among the patients receiving thrombolysis and decompressive rib resection, 46.8% (164 of 350) patients had <14 d between interventions, 19.1% (67 of 350) patients had 14-30 d between interventions, and 34.0% (119 of 350) had >30 d between interventions. There were no significant differences in postoperative bleeding between patients with <14 d, 14-30 d, and >30 d between thrombolysis and surgery. In terms of number of hospital visits, 19.0% (112 of 590) had "simultaneous" thrombolysis and surgery and 40.5% (239 of 590) had thrombolysis and surgery in a "staged" approach. Forty point five percent (239 of 590) of patients received only surgical decompression without thrombolysis. CONCLUSIONS Thrombolysis followed by first rib resection for vTOS can be performed during the same hospital admission without an associated risk of bleeding complications.
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Affiliation(s)
- Victoria Yin
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Brooks V Udelsman
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Alexander T Kim
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Sean C Wightman
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Graeme M Rosenberg
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Scott M Atay
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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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; 12:101936. [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] [MESH Headings] [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
BACKGROUND We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). METHODS We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before 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 = .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 rethrombosis 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. CONCLUSIONS Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although 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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Ng JC, Tan LT, Mofid A, Holscher CM, White JM, Hicks CW, Abularrage CJ, Freischlag JA, Lum YW. Surgical outcomes for occluded venous thoracic outlet syndrome following transaxillary first rib resection. J Vasc Surg Venous Lymphat Disord 2024; 12:101925. [PMID: 38914374 DOI: 10.1016/j.jvsv.2024.101925] [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] [Received: 04/16/2024] [Revised: 05/30/2024] [Accepted: 06/01/2024] [Indexed: 06/26/2024]
Abstract
OBJECTIVE Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS. METHODS We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ2 test to compare baseline characteristics and postoperative outcomes. RESULTS Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84). CONCLUSIONS TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency.
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Affiliation(s)
- Jyi Cheng Ng
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Li Ting Tan
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alireza Mofid
- Sparrow Cardiovascular and Thoracic Surgery, E.W. Sparrow Hospital, Lansing, MI
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph M White
- Department of Surgery, Suburban Hospital, Johns Hopkins University School of Medicine, Bethesda, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Julie A Freischlag
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ying Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
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Wood EC, Velazquez G. First rib fix: The venography timing dilemma. J Vasc Surg Venous Lymphat Disord 2024; 12:101937. [PMID: 39160003 DOI: 10.1016/j.jvsv.2024.101937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 06/16/2024] [Indexed: 08/21/2024]
Affiliation(s)
- Elizabeth C Wood
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Gabriela Velazquez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC
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Crossland DT, Overturf MD. Paget-Schroetter Syndrome: A Case of a Young Weightlifter. Cureus 2024; 16:e62824. [PMID: 39036114 PMCID: PMC11260354 DOI: 10.7759/cureus.62824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/20/2024] [Indexed: 07/23/2024] Open
Abstract
Venous thoracic outlet syndrome is a rare type of thoracic outlet disorder that is often overlooked. When an upper extremity deep vein thrombosis (UEDVT) occurs due to thoracic outlet compression, it is commonly referred to as Paget-Schroetter syndrome (PSS). The space between the first rib and the clavicle where the subclavian vein passes through is highly vulnerable to compression and injury. This space often undergoes repetitive trauma due to extrinsic compression which ultimately results in scarring and clot formation. This case report reviews the case of a 26-year-old white male who presented with the chief complaint of right arm swelling and soreness after strenuous bench pressing. He went to urgent care and the initial diagnosis was a strained muscle. An ultrasound was ordered, revealing multiple UEDVTs. At this time, the patient was referred to vascular surgery for further management. Recommended management for PSS is to initiate anticoagulation or thrombolytic therapy depending on the timing between the onset of symptoms and diagnosis. Although there is some disagreement on the next steps after thrombolysis, most physicians agree that decompression of the thoracic outlet with first rib resection is the logical next step to prevent clot recurrence. The patient received the above-mentioned therapy and is progressing well with recovery. Recognizing the thoracic outlet as a potential location for pathology and keeping in mind those who have a presentation similar to this case study is extremely important.
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Affiliation(s)
| | - Matthew D Overturf
- Anatomical Sciences, Edward Via College of Osteopathic Medicine, Monroe, USA
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Velazquez G. Balancing choices in Paget-Schroetter Syndrome: Navigating streamlined patient-focused strategies. J Vasc Surg Venous Lymphat Disord 2024; 12:101716. [PMID: 38631803 DOI: 10.1016/j.jvsv.2023.101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 04/19/2024]
Affiliation(s)
- Gabriela Velazquez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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Khoury MK, Thornton MA, Dua A. Systematic review of intermediate and long-term results of thoracic outlet decompression. Semin Vasc Surg 2024; 37:90-97. [PMID: 38704189 DOI: 10.1053/j.semvascsurg.2024.01.001] [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] [Received: 09/26/2023] [Revised: 12/06/2023] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
Thoracic outlet syndrome (TOS) consists of a group of disorders resulting from compression of the neurovascular bundle exiting through the thoracic outlet. TOS can be classified as follows based on the etiology of the pathophysiology: neurogenic TOS, venous TOS, arterial TOS, and mixed TOS. The constellation of symptoms a patient may experience varies, depending on the structures involved. Due to the wide range of etiologies and presenting symptoms, treatments for TOS also differ. Furthermore, most studies focus on the perioperative and short-term outcomes after surgical decompression for TOS. This systematic review aimed to provide a pooled analysis of studies to better understand the intermediate and long-term outcomes of surgical decompression for TOS. We conducted a systematic literature search in the Ovid MEDLINE, Embase, and Google Scholar databases for studies that analyzed long-term outcomes after surgical decompression for TOS. The inclusion period was from January 2015 to May 2023. The primary outcome was postoperative QuickDASH Outcome Measure scores. A total of 16 studies were included in the final analysis. The differences between postoperative and preoperative QuickDASH Outcome Measure scores were calculated, when possible, and there was a mean overall difference of 33.5 points (95% CI, 25.2-41.8; P = .001) after surgical decompression. There was a higher proportion of excellent outcomes reported for patients undergoing intervention for arterial and mixed TOS etiologies, whereas those with venous and neurogenic etiologies had the lowest proportion of excellent outcomes reported. Patients with neurogenic TOS had the highest proportion of poor outcomes reported. In conclusion, surgical decompression for TOS has favorable long-term outcomes, especially in patients with arterial and mixed etiologies.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA, 02114
| | - Micah A Thornton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA, 02114
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA, 02114.
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Davies MG, Hart JP. Endovascular management of acute and subacute venous thoracic outlet syndrome. Front Surg 2024; 11:1302568. [PMID: 38440414 PMCID: PMC10909919 DOI: 10.3389/fsurg.2024.1302568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Approximately 3% of all patients presenting with Thoracic Outlet Syndrome have a venous etiology (vTOS), which is considered "effort thrombosis". These patients will present with symptomatic deep venous thrombosis or focal subclavian vein (SCV) stenosis. Endovascular management of vTOS occurs in several phases: diagnostic, preoperative therapeutic intervention before decompression, postoperative interventions after decompression, and delayed interventions in the follow-up after decompression. In the diagnostic phase, dynamic SCV venography can establish functional vTOS. Approximately 4,000 patients have been treated for vTOS and reported in the literature since 1970. Declotting of the SCV was followed by surgical decompression in 53% of patients, while in the remainder, surgical decompression alone (18%), endovascular intervention alone (15%), or conservative therapy with anticoagulation (15%) was performed. The initial intervention was predominantly catheter-directed thrombolysis, with <10% of cases undergoing concomitant balloon angioplasty. 93% of cases were successful. In the postoperative phase, balloon angioplasty was performed to correct residual intrinsic SCV disease after vTOS decompression in under 15% of cases. Stents were rarely deployed. Symptom relief was reported as 94 ± 12% (mean ± SD) and 90 ± 23%, respectively for declotting with decompression and declotting alone. In the delayed phase, balloon angioplasty was performed in under 15% of cases to re-establish patency.
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Affiliation(s)
- Mark G. Davies
- Department of Cardiovascular Outcomes, Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
| | - Joseph P. Hart
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Schropp L, Westerink J, Nijkeuter M, van Hattum ES, Petri BJ, de Borst GJ. Severe selection bias in deemed venous thoracic outlet syndrome-associated upper extremity deep venous thrombosis research. J Vasc Surg 2023; 78:841-842. [PMID: 37599038 DOI: 10.1016/j.jvs.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Ludo Schropp
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Mathilde Nijkeuter
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eline S van Hattum
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart-Jeroen Petri
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Dadashzadeh ER, Ohman JW, Kavali PK, Henderson KM, Goestenkors DM, Thompson RW. Reply. J Vasc Surg 2023; 78:842-843. [PMID: 37599040 DOI: 10.1016/j.jvs.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Esmaeel Reza Dadashzadeh
- The Center for Thoracic Outlet Syndrome and Sections of Vascular Surgery, Department of Surgery, and Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - J Westley Ohman
- The Center for Thoracic Outlet Syndrome and Sections of Vascular Surgery, Department of Surgery, and Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Pavan K Kavali
- The Center for Thoracic Outlet Syndrome and Sections of Vascular Surgery, Department of Surgery, and Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Karen M Henderson
- The Center for Thoracic Outlet Syndrome and Sections of Vascular Surgery, Department of Surgery, and Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Danita M Goestenkors
- The Center for Thoracic Outlet Syndrome and Sections of Vascular Surgery, Department of Surgery, and Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Robert W Thompson
- The Center for Thoracic Outlet Syndrome and Sections of Vascular Surgery, Department of Surgery, and Vascular Interventional Radiology, Department of Radiology, Washington University School of Medicine, St. Louis, MO
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Freischlag JA. It is all about the rib or is it. J Vasc Surg 2023; 77:890. [PMID: 36822767 DOI: 10.1016/j.jvs.2022.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 02/23/2023]
Affiliation(s)
- Julie Ann Freischlag
- Atrium Health Wake Forest Baptist, Winston-Salem, NC; Wake Forest University School of Medicine, Winston-Salem, NC; Advocate Health, Downers Grove, IL
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