scholarly journals Modern Diagnosis and Surgical Management of Thoracic Outlet Syndrome: A Comprehensive Review

2021 ◽  
pp. 27
Author(s):  
Keyword(s):  
Upper Extremity ◽  
Subclavian Vein ◽  
Transverse Process ◽  
Venous Hypertension ◽  
Cervical Rib ◽  
First Rib ◽  
Extrinsic Compression ◽  
Robotic Resection ◽  
Entrapment Syndromes ◽  
Neurogenic Tos

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.

scholarly journals The infraclavicular approach for Paget–Schroetter syndrome

2018 ◽  
Vol 100 (2) ◽  
pp. 83-91 ◽  
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.

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

Injury ◽  
1995 ◽  
Vol 26 (1) ◽  
pp. 57-58 ◽  
Author(s):  
F.W. Rozendaal ◽  
H.J. Bonjer ◽  
H.A. Bruining
Keyword(s):  
Subclavian Vein ◽  
First Rib

Proposed pathogenesis of Paget–Schroetter disease: impingement of the subclavian vein by a congenitally malformed bony tubercle on the first rib

2011 ◽  
Vol 65 (3) ◽  
pp. 262-266 ◽  
Author(s):  
Farid Gharagozloo ◽  
Mark Meyer ◽  
Barbara Tempesta ◽  
Eric Strother ◽  
Marc Margolis ◽  
...  
Keyword(s):  
Subclavian Vein ◽  
First Rib

The First Rib as a Fluoroscopic Marker for Subclavian Vein Access

1995 ◽  
Vol 6 (4) ◽  
pp. 619-622 ◽  
Author(s):  
Paul F. Jaques ◽  
William E. Campbell ◽  
Siobhan Dumbleton ◽  
Matthew A. Mauro
Keyword(s):  
Subclavian Vein ◽  
First Rib ◽  
Vein Access

scholarly journals Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome

Hand ◽  
2018 ◽  
Vol 14 (5) ◽  
pp. 636-640 ◽  
Author(s):  
Kevin T. Jubbal ◽  
Dmitry Zavlin ◽  
Joshua D. Harris ◽  
Shari R. Liberman ◽  
Anthony Echo
Keyword(s):  
Thoracic Outlet Syndrome ◽  
Operative Time ◽  
Medical Complications ◽  
Complication Rates ◽  
Improvement Program ◽  
Cervical Rib ◽  
Rib Resection ◽  
First Rib ◽  
Increased Risk ◽  
First Rib Resection

Background: Thoracic outlet syndrome (TOS) is a complex entity resulting in neurogenic or vascular manifestations. A wide array of procedures has evolved, each with its own benefits and drawbacks. The authors hypothesized that treatment of TOS with first rib resection (FRR) may lead to increased complication rates. Methods: A retrospective case control study was performed on the basis of the National Surgical Quality Improvement Program database from 2005 to 2014. All cases involving the operative treatment of TOS were extracted. Primary outcomes included surgical and medical complications. Analyses were primarily stratified by FRR and secondarily by other procedure types. Results: A total of 1853 patients met inclusion criteria. The most common procedures were FRR (64.0%), anterior scalenectomy with cervical rib resection (32.9%), brachial plexus decompression (27.2%), and anterior scalenectomy without cervical rib resection (AS, 8.9%). Factors associated with increased medical complications included American Society of Anesthesiologists (ASA) classification of 3 or greater and increased operative time. The presence or absence of FRR did not influence complication rates. Conclusions: FRR is not associated with an increased risk of medical or surgical complications. Medical complications are associated with increased ASA scores and longer operative time.

Iliocaval Compression Syndrome

1987 ◽  
Vol 2 (3) ◽  
pp. 173-179 ◽  
Author(s):  
Syde A. Taheri ◽  
Paul Nowakowski ◽  
David Pendergast ◽  
Julie Cullen ◽  
Steve Pisano ◽  
...  
Keyword(s):  
Iliac Artery ◽  
Common Iliac Artery ◽  
Vena Cava ◽  
Signs And Symptoms ◽  
Iliac Vein ◽  
Venous Hypertension ◽  
Common Iliac Vein ◽  
Compression Syndrome ◽  
Extrinsic Compression ◽  
The Right

The iliocaval compression syndrome is a disorder, frequently found in young women, in which extrinsic compression of the left iliocaval junction produces signs and symptoms of lower extremity venous insufficiency. The anatomic variant which gives rise to this syndrome consists of compression of the left common iliac vein by the overlying right common iliac artery, near its junction with the vena cava. Additional reduction of outflow results from intraluminal venous webs and tight adhesions between the iliac artery and vein. Pain, swelling, pigmentation, and venous claudication characterize this syndrome, which affects predominantly the left leg. The syndrome may progress to iliofemoral thrombosis, phlegmasia cerulea dolens, and venous gangrene. Longstanding iliocaval stenosis may produce valvular incompetence. Exercise plethysmography is a non-invasive test useful in screening patients for iliocaval compression. The definitive diagnosis is made by venography, both ascending and descending, to determine the degree of outflow stenosis. Iliocaval patch angioplasty with retrocaval positioning of the right iliac artery, decreases venous hypertension and leads to improvement in the clinical condition. To date, we have performed iliocaval angioplasty, with retrocaval repositioning of the right common iliac artery, on 18 patients. Of these, 83% have had good results as determined by hemodynamic and clinical assessment.

Sign in / Sign up

Export Citation Format

Share Document