Bilateral arterial thoracic outlet syndrome with intermittent subclavian artery occlusion

A review of arterial thoracic outlet syndrome

Arterial thoracic outlet syndrome (TOS) is a condition in which anatomic abnormalities in the thoracic outlet cause compression of the subclavian or, less commonly, axillary artery. Patients are usually younger and typically have an anatomic abnormality causing the compression. The condition usually goes undiagnosed until patients present with signs of acute or chronic hand or arm ischemia. Workup of this condition includes a thorough history and physical examination; chest x-ray to identify potential anatomic abnormalities; and arterial imaging, such as computed tomographic angiography or duplex to identify arterial abnormalities. Patients will usually require operative intervention, given their symptomatic presentation. Intervention should always include decompression of the thoracic outlet with at least a first-rib resection and any other structures causing external compression. If the artery is identified to have intimal damage, mural thrombus, or is aneurysmal, then arterial reconstruction is warranted. Stenting should be avoided due to external compression. In patients with symptoms of embolization, a combination of embolectomy, lytic catheter placement, and/or therapeutic anticoagulation should be done. Typically, patients have excellent outcomes, with resolution of symptoms and high patency of the bypass graft, although patients with distal embolization may require finger amputation.

30-year Single Center Experience with Arterial Thoracic Outlet Syndrome

OBJECTIVES

Arterial thoracic outlet syndrome (ATOS) is rare. We present our 30-year experience with management of ATOS at a high-volume referral center.

METHODS

A retrospective review of all patients who underwent primary operative treatment for ATOS from 1988 to 2018 was performed. ATOS was defined as subclavian artery pathology caused by extrinsic compression from a bony abnormality within the thoracic outlet.

RESULTS

Forty-one patients (forty-five limbs) underwent surgical treatment for ATOS with a median age of 46 years (IQR 34-58 years). Chronic symptoms (>6 weeks) were present in 31 patients (69%). Thirteen patients (29%) presented with acute limb ischemia (ALI) requiring urgent brachial artery thromboembolectomy (BAT) in nine and catheter-directed thrombolysis and thrombectomy (CDT) in four. All patients underwent thoracic outlet decompression. Thirty-one patients (69%) required subclavian artery reconstruction. There were no perioperative deaths and only one major adverse limb event. Patients with ALI had staged thoracic outlet decompression after initial BAT or CDT at a median of 23 days (IQR 11-140 days). Eight patients (62%) whose initial presentation was ALI had recurrent thromboembolic events prior to thoracic outlet decompression subsequently requiring ten additional BATs and one CDT. The cumulative probability of recurrent embolization at 14 days, 30 days and 90 days was 8.33% (CI 1.28-54.42%), 16.67% (CI 4.70-59.06%) and 33.33% (14.98-74.20%) respectively. Thirty-two patients had follow-up at a median of 13 months (IQR 5-36). Subclavian artery/graft primary and secondary patency were 87% and 90% respectively at 5 years by Kaplan Meier analysis. Five (14%) had chronic upper extremity pain and five (14%) had persistent weakness. Preoperative forearm or hand pain and brachial artery occlusion were associated with chronic pain (P = .04 and P = .03) and weakness (P = .03 and P = .02). Eleven patients who presented with ALI had follow-up after thoracic outlet decompression at a median of 6 months (IQR 5-14), including nine (82%) who were discharged on oral anticoagulation. Anticoagulation had no effect on patency (P = 1.0) or chronic symptoms (P = .93).

CONCLUSIONS

The presentation of ATOS is diverse and diagnosis can be delayed. Preoperative upper extremity pain and brachial artery occlusion in the setting of ALI were associated with chronic pain and weakness following thoracic outlet decompression. Delayed thoracic outlet decompression was associated with an increased risk of recurrent thromboembolic events in patients who presented with ALI. An early and accurate diagnosis of ATOS is necessary to reduce morbidity and optimize outcomes.