Late haemorrhage from the subclavian vein due to a fracture of the first rib

Conventionally TOS has been thought to represent a group of diverse disorders that result in compression of the neurovascular bundle exiting the thoracic outlet. Until recently, TOS classification has been based on symptoms, rather than the underlying pathology, with the subgroups consisting of neurogenic (NTOS), venous (VTOS or PSS), and arterial (ATOS). Neurogenic TOS accounts for over 95% of the cases, followed by venous (3–5%) and arterial (1–2%). Neurogenic TOS (NTOS) has been further divided into True NTOS (TNTOS) and Disputed NTOS (DNTOS), with DNTOS reportedly representing 95–99% of all neurogenic cases. In order to decrease confusion and to improve therapeutic results with TOS, the disease should be classified based on the underlying pathologic entity. Acquired and traumatic abnormalities of the clavicle and first rib should be classified separately. Clearly after the more common and objectively supported diagnoses of conditions that result in neurovascular symptoms of the upper extremity, such as cervical spine disease, carpal tunnel disease, and nerve entrapment syndromes, have been ruled out, there remains a group of patients who are suspected of having TOS. In these patients, rather than the more usual classification such as arterial, venous, or neurogenic, the more accurate approach from a diagnostic and therapeutic approach is to classify them as: Cervical Rib Disease: Patients with cervical rib syndrome (CRS) can have complications relating to compression of the subclavian artery (previously referred to as ATOS) and the brachial plexus(previously referred to as True NTOS) secondary to a well-formed cervical rib, or to an incompletely formed first rib, fibrous band associated with a rudimentary cervical rib, or a giant transverse process of C7. Thoracic Outlet Disease or “Subclavian Vein Compression Syndrome”: In these patients an abnormal first rib at its junction with the sternum results in compression of the subclavian vein at the subclavian-innominate junction. Compression of the vein results in venous hypertension in the upper extremity and resultant neurologic symptoms. With prolonged compression of the subclavian-innominate junction, the vein clots giving rise to Paget–Schroetter syndrome. Therefore, patients who have been previously classified as Disputed Neurogenic and Venous TOS represent a variable symptomatic presentation of the same pathologic entity, which affects the subclavian vein. Presently MRA of the thoracic outlet with arm maneuvers is the test of choice in patients suspected of having TOS. This test shows the abnormal bony tubercle on the first rib with extrinsic compression of the subclavian innominate junction, which is exacerbated with elevation of the arm above the shoulder. Robotic resection of the medial aspect of the first rib along with disarticulation of the costo-sternal joint has the best reported results to date.

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Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension Due to Subclavian Vein Thrombosis From Bilateral First Rib Anomaly

CHEST Journal ◽

10.1378/chest.2227563 ◽

2015 ◽

Vol 148 (4) ◽

pp. 975A

Author(s):

Stephanie Shin ◽

Peter Fedullo ◽

Theodore Frank ◽

William Auger

Keyword(s):

Pulmonary Hypertension ◽

Subclavian Vein ◽

Chronic Thromboembolic Pulmonary Hypertension ◽

Pulmonary Thromboendarterectomy ◽

Vein Thrombosis ◽

Subclavian Vein Thrombosis ◽

First Rib ◽

Thromboembolic Pulmonary Hypertension

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The infraclavicular approach for Paget–Schroetter syndrome

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2017.0154 ◽

2018 ◽

Vol 100 (2) ◽

pp. 83-91 ◽

Cited By ~ 4

Author(s):

G Samoila ◽

CP Twine ◽

IM Williams

Keyword(s):

Subclavian Vein ◽

Thrombotic Event ◽

Young Male ◽

Symptom Duration ◽

Secondary Patency ◽

Supraclavicular Approach ◽

First Rib ◽

Extrinsic Compression ◽

Catheter Directed Thrombolysis ◽

Effort Thrombosis

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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