Subclavian Vessel Compression Assessed by Duplex Scanning in Patients with Neurogenic Thoracic Outlet Syndrome and No Vascular Signs

Neurogenic thoracic outlet syndrome (NTOS) is the most frequent form of TOS. It may affect both sides, but specific complementary exams are lacking. We aimed to evaluate duplex scanning results in a group of patients with unilateral or bilateral NTOS and no clinical vascular signs, referred for rehabilitation. We performed a retrospective observational study in patients with unilateral or bilateral NTOS and no vascular symptoms. Subclavian vessels were assessed by duplex scanning. Compressions were considered in case of >50% of increased or decreased blood flow. A total of 101 patients met NTOS criteria; mean age was 40 +/− 10.2; 79.2% women. Seventy patients had a unilateral NTOS and 31 a bilateral form. Duplex scanning showed that 56.4% of the patients had vessels compression, 55.7% in the unilateral group and 58.1% in the bilateral (p = 0.81). In unilateral NTOS, 21 (30%) patients had bilateral vascular compression, 17 (24.3%) had ipsilateral compression and 1 (1.4%) had contralateral compression. In bilateral NTOS, 15 (48.4%) had bilateral compression and 3 (9.7%) compression on only one side. We found a significant difference of the rate of vascular compressions between symptomatic and non-symptomatic upper-limbs, 54.5% vs. 32.9%, respectively, (p = 0.002) and a significant association between symptomatic upper-limbs and vascular compression (OR = 2.45 [95%IC: 1.33–4.49]; p = 0.002). The sensitivity and the specificity of the duplex scanning were 54.5% and 67%, respectively. The ROC curve area was of 0.608 [95%IC: 0.527–0.690]. Despite a highly significant association between symptomatic upper-limbs and vascular compression, duplex scanning did not help make the diagnosis of NTOS.

High prevalence of early arch reobstruction after arch repair in patients with anomalous right subclavian artery

OBJECTIVES Having an anomalous right subclavian artery has been quoted to be a risk factor for early and late adverse events. We wanted to determine the rate of adverse outcomes in patients who have undergone arch repair with an associated anomalous right subclavian artery. METHODS The follow-up of 76 patients, with an anomalous right subclavian artery, who underwent arch repair at a single institution for various indications between 1981 and 2017 was reviewed. RESULTS There were 12 patient deaths. Twenty-three patients required an aortic arch reintervention (17 surgeries, 2 of which were indicated for bronchial obstruction). At last follow-up, 8 of 54 surviving patients (15%) had arch reobstruction (peak gradient >25 mmHg or reintervention). Freedom from aortic arch obstruction at 10 and 15 years was 51% [95% confidence interval (CI) 36–65%] and 35% (95% CI 19–51%), respectively. Neither the complete resection of the adjacent ridge nor the detachment and reimplantation of the anomalous subclavian vessel seemed to have an impact on the rate of reobstruction [hazard ratio (HR) 1.6, 95% CI 0.77–3.5; P = 0.2 and HR 0.61, 95% CI 0.083–4.5; P = 0.6, respectively]. CONCLUSIONS Patients with an anomalous right subclavian artery are at risk of arch reobstruction necessitating reintervention but long-term follow-up was unable to demonstrate the mechanism of this obstruction in patients with this anomaly.

Hemothorax - A Complication of Subclavian Vein Cannulation

Massive bleeding into pleural cavity after subclavian vein cannulation is a rather rare but very serious complication. Usually laceration of the venous wall is the cause. In patients where conservative treatment, i.e. pleural drainage, maintaining the circulatory volume, treatment of possible coagulopathy, etc. is ineffective, surgery has to be performed. Bleeding can be surgically managed either from posterolateral thoracotomy or direct subclavian vessel revision is possible after partial resection of the clavicle. Brachiocephalic vein bleeding can be approached and managed through median sternotomy. We present a case report of 22-year old man with hemothorax after subclavian vein cannulation. In our patient only complex surgical procedure enabled proper management of bleeding complication.