1
|
Hoexum F, Jongkind V, Coveliers HME, Wisselink W, Yeung KK. Long-Term Outcomes of Nonoperative and Surgical Management of Paget-Schroetter Syndrome. J Endovasc Ther 2024; 31:171-177. [PMID: 36082395 PMCID: PMC10938484 DOI: 10.1177/15266028221120360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE In Paget-Schroetter Syndrome (PSS), subclavian vein thrombosis is caused by external compression of the subclavian vein at the costoclavicular junction. Paget-Schroetter Syndrome can be treated nonoperatively, surgically, or with a combination of treatments. Nonoperative management consists, in most cases, of anticoagulation (AC) or catheter-directed thrombolysis (CDT). With surgical management, decompression of the subclavian vein is performed by resection of the first rib. No prospective randomized trials are available to determine whether nonoperative or surgical management is superior. We report our long-term outcomes of both nonoperative and surgically treated patients. MATERIALS AND METHODS We retrospectively analyzed all patients with PSS who were treated between January 1990 and December 2015. Patients were divided based on primary nonoperative or primary surgical therapy. Long-term outcomes regarding functional outcomes were assessed by questionnaires using the "Disability of the Arm, Shoulder, and Hand" (DASH) questionnaire, a modified Villalta score, and a disease-specific question regarding lifestyle changes. RESULTS In total, 91 patients (95 limbs) were included. Seventy patients (73 limbs) were treated nonoperatively and 21 patients (22 limbs) surgically. Questionnaires were returned by 67 patients (70 limbs). The mean follow-up was 184 months (range, 43-459 months). All functional outcomes were better in the surgical group compared with the nonoperatively treated group (DASH general 3.11 vs 9.86; DASH work 0.35 vs 11.47; DASH sport 5.85 vs 17.98, and modified Villalta score 1.11 vs 3.20 points). Surgically treated patients were more likely to be able to continue their original lifestyle and sports activities (84% vs 40%, p=0.005). Patients with recurrence of thrombosis or the need for surgical intervention after primary nonoperative management reported worse functional outcomes. CONCLUSION Surgical management of PSS with immediate CDT followed by first rib resection leads to excellent functional outcomes with low risk of complications. The results of nonoperative management in our non-matched retrospective comparative series were satisfactory, but resulted in worse functional outcomes and more patients needing to adjust their lifestyle compared with surgically treated patients. CLINICAL IMPACT Patients with Paget-Schroetter Syndrome and their attending physicians are burdened by the lack of evidence concerning the optimal treatment of this entity. Case series comparing the outcomes of non-operative treatment with surgical treatment are scarce and often not focussed on functional outcomes. Data from this series can aid in the shared decision making after diagnosis of Paget-Schroetter Syndrome. Functional outcomes of non-operative management can be satisfying although high demand patient who are not willing to alter their daily activities are probably better off with surgical management.
Collapse
Affiliation(s)
- Frank Hoexum
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Willem Wisselink
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Hoexum F, Hoebink M, Coveliers HME, Wisselink W, Jongkind V, Yeung KK. Management of Paget-Schroetter Syndrome: a Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 66:866-875. [PMID: 37678659 DOI: 10.1016/j.ejvs.2023.08.065] [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: 05/31/2022] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Currently, there is no consensus on the optimal management of Paget-Schroetter syndrome (PSS). The objective was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies. DATA SOURCES The Cochrane, PubMed, and Embase databases were searched for reports published between January 1990 and December 2021. REVIEW METHODS A systematic review and meta-analysis was conducted following PRISMA 2020 guidelines. The primary endpoint was the proportion of symptom free patients at last follow up. Secondary outcomes were success of initial treatment, recurrence of thrombosis or persistent occlusion, and patency at last follow up. Meta-analyses of the primary endpoint were performed for non-comparative and comparative reports. The quality of evidence was assessed using the GRADE approach. RESULTS Sixty reports were included (2 653 patients), with overall moderate quality. The proportions of symptom free patients in non-comparative analysis were: anticoagulation (AC), 0.54; catheter directed thrombolysis (CDT) + AC, 0.71; AC + first rib resection (FRR), 0.80; and CDT + FRR, 0.96. Pooled analysis of comparative reports confirmed the superiority of CDT + FRR compared with AC (OR 13.89, 95% CI 1.08 - 179.04; p = .040, I2 87%, very low certainty of evidence), AC + FRR (OR 2.29, 95% CI 1.21 - 4.35; p = .010, I2 0%, very low certainty of evidence), and CDT + AC (OR 8.44, 95% CI 1.12 - 59.53; p = .030, I2 63%, very low certainty of evidence). Secondary endpoints were in favour of CDT + FRR. CONCLUSION Non-operative management of PSS with AC alone results in persistent symptoms in 46% of patients, while 96% of patients managed with CDT + FFR were symptom free at end of follow up. Superiority of CDT + FRR compared with AC, CDT + AC, and AC + FRR was confirmed by meta-analysis. The overall quality of included reports was moderate, and the level of certainty was very low.
Collapse
Affiliation(s)
- Frank Hoexum
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Max Hoebink
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | | | - Willem Wisselink
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| |
Collapse
|
3
|
Reyes M, Alaparthi S, Roedl JB, Moreta MC, Evans NR, Grenda T, Okusanya OT. Robotic First Rib Resection in Thoracic Outlet Syndrome: A Systematic Review of Current Literature. J Clin Med 2023; 12:6689. [PMID: 37892829 PMCID: PMC10607688 DOI: 10.3390/jcm12206689] [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: 09/05/2023] [Revised: 10/14/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Thoracic outlet syndrome (TOS) involves the compression of neurovascular structures in the thoracic outlet. TOS subtypes, including neurogenic (nTOS), venous (vTOS), and arterial (aTOS) are characterized by distinct clinical presentations and diagnostic considerations. This review explores the incidence, diagnostic challenges, and management of TOS with a focus on the innovative approach of Robotic First Rib Resection (R-FRR). Traditional management of TOS includes conservative measures and surgical interventions, with various open surgical approaches carrying risks of complications. R-FRR, a minimally invasive technique, offers advantages such as improved exposure, reduced injury risk to neurovascular structures, and shorter hospital stays. A comprehensive literature review was conducted to assess the outcomes of R-FRR for TOS. Data from 12 selected studies involving 397 patients with nTOS, vTOS, and aTOS were reviewed. The results indicate that R-FRR is associated with favorable intraoperative outcomes including minimal blood loss and low conversion rates to traditional approaches. Postoperatively, patients experienced decreased pain, improved function, and low complication rates. These findings support R-FRR as a safe and effective option for medically refractory TOS.
Collapse
Affiliation(s)
- Maikerly Reyes
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Sneha Alaparthi
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| | - Johannes B. Roedl
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA;
| | - Marisa C. Moreta
- Department of Rehabilitation Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA;
| | - Nathaniel R. Evans
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| | - Tyler Grenda
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| | - Olugbenga T. Okusanya
- Department of Thoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA; (S.A.); (N.R.E.); (T.G.)
| |
Collapse
|
4
|
Schropp L, de Kleijn RJCMF, Westerink J, Nijkeuter M, Vonken EJ, van der Schaaf IC, Goedee HS, Vrancken AFJE, van Hattum ES, Petri BJ, de Borst GJ. Thoracic outlet syndrome (TROTS) registry: A study protocol for the primary upper extremity deep venous thrombosis section. PLoS One 2023; 18:e0279708. [PMID: 36608058 PMCID: PMC9821680 DOI: 10.1371/journal.pone.0279708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION There is a lack of comprehensive and uniform data on primary upper extremity deep venous thrombosis (pUEDVT). pUEDVT includes venous thoracic outlet syndrome related upper extremity deep venous thrombosis (UEDVT) and idiopathic UEDVT. Research on these conditions has been hampered by their rarity, lack of uniform diagnostic criteria, and heterogeneity in therapeutic strategies. To improve current research data collection using input of all various pUEDVT treating medical specialists, we initiated the ThoRacic OuTlet Syndrome (TROTS) registry. The aim of the TROTS registry is to a) collect extensive data on all pUEDVT patients through a predefined protocol, b) give insight in the long term outcome using patient reported outcome measures, c) create guidance in the diagnostic and clinical management of these conditions, and thereby d) help provide content for future research. METHODS AND ANALYSIS The TROTS registry was designed as an international prospective longitudinal observational registry for data collection on pUEDVT patients. All pUEDVT patients, regardless of treatment received, can be included in the registry after informed consent is obtained. All relevant data regarding the initial presentation, diagnostics, treatment, and follow-up will be collected prospectively in an electronic case report form. In addition, a survey containing general questions, a Health-related Quality of Life questionnaire (EQ-5D-5L), and Functional Disability questionnaire (Quick-DASH) will be sent periodically (at the time of inclusion, one and two years after inclusion, and every five years after inclusion) to the participant. The registry protocol was approved by the Medical Ethical Review Board and registered in the Netherlands Trial Register under Trial-ID NL9680. The data generated by the registry will be used for future research on pUEDVT and published in peer reviewed journals. CONCLUSION TROTS registry data will be used to further establish the optimal management of pUEDVT and lay the foundation for future research and guidelines.
Collapse
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
| | - Evert-Jan Vonken
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - H. Stephan Goedee
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander F. J. E. Vrancken
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center 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
- * E-mail:
| | | |
Collapse
|
5
|
Thoracic outlet syndrome: a retrospective analysis of robotic assisted first rib resections. J Robot Surg 2022; 17:891-896. [DOI: 10.1007/s11701-022-01486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
|
6
|
Gkikas A, Lampridis S, Patrini D, Kestenholz PB, Azenha LF, Kocher GJ, Scarci M, Minervini F. Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review. Front Surg 2022; 9:848972. [PMID: 35350142 PMCID: PMC8957785 DOI: 10.3389/fsurg.2022.848972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThoracic outlet syndrome (TOS) is a pathological condition caused by a narrowing between the clavicle and first rib leading to a compression of the neurovascular bundle to the upper extremity. The incidence of TOS is probably nowadays underestimated because the diagnosis could be very challenging without a thorough clinical examination along with appropriate clinical testing. Beside traditional supra-, infraclavicular or transaxillary approaches, the robotic assisted first rib resection has been gaining importance in the last few years.MethodsWe conducted a retrospective cohort analysis of all patients who underwent robotic assisted first rib resection due to TOS at Lucerne Cantonal Hospital and then we performed a narrative review of the English literature using PubMed, Cochrane Database of Systematic Reviews and Scopus.ResultsBetween June 2020 and November 2021, eleven robotic assisted first rib resections were performed due to TOS at Lucerne Cantonal Hospital. Median length of stay was 2 days (Standard Deviation: +/– 0.67 days). Median surgery time was 180 min (Standard Deviation: +/– 36.5). No intra-operative complications were reported.ConclusionsRobotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.
Collapse
Affiliation(s)
- Andreas Gkikas
- Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
| | - Savvas Lampridis
- Department of Thoracic Surgery, 424 General Military Hospital, Thessaloniki, Greece
| | - Davide Patrini
- Department of Thoracic Surgery, University College London Hospitals, London, United Kingdom
| | - Peter B. Kestenholz
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Luis Filipe Azenha
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Gregor Jan Kocher
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Scarci
- Department of Thoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
- *Correspondence: Fabrizio Minervini
| |
Collapse
|
7
|
Zehnder A, Lutz J, Dorn P, Minervini F, Kestenholz P, Gelpke H, Schmid RA, Kocher GJ. Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment? J Clin Med 2021; 10:3952. [PMID: 34501401 PMCID: PMC8432239 DOI: 10.3390/jcm10173952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71-270 min (median 128.5 min, SD +/- 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/- 2.1 days). Stent grafting was performed 5-35 days (mean 14.8 days, SD +/- 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.
Collapse
Affiliation(s)
- Adrian Zehnder
- Department of Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland; (A.Z.); (H.G.)
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Jon Lutz
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Patrick Dorn
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Kantonsspital Luzern, 6004 Lucerne, Switzerland; (F.M.); (P.K.)
| | - Peter Kestenholz
- Department of Thoracic Surgery, Kantonsspital Luzern, 6004 Lucerne, Switzerland; (F.M.); (P.K.)
| | - Hans Gelpke
- Department of Surgery, Cantonal Hospital of Winterthur, 8401 Winterthur, Switzerland; (A.Z.); (H.G.)
| | - Ralph A. Schmid
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| | - Gregor J. Kocher
- Division of General Thoracic Surgery, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (J.L.); (P.D.); (R.A.S.)
| |
Collapse
|