Vol 5, No 3 (2003)
Published online: 2003-10-07
The treatment of vascular thoracic outlet syndrome
Chirurgia Polska 2003;5(3):119-127.
Abstract
Background: In this paper the treatment of vascular (venous and arterial) complications of the Thoracic Outlet Syndrome (TOS) is presented.
Material and methods: An investigation of 37 patients treated in the Department of Vascular, General and Transplantological Surgery of the Wroclaw Medical University for vascular complications of the TOS (Paget-Schroetter syndrome in 23 patients as well as upper limb ischemia and/or the subclavian artery aneurysm in 14 patients) was performed. In the case of venous thrombosis the treatment consisted of thrombolytic therapy (mainly recombinant tissue-type plasminogen activator - rt-PA), the use of anticoagulation (also oral anticoagulants) and decompressive procedures that included transaxillary first rib resection and the other surgical procedures that excise different anomalies in the region of the thoracic outlet. In cases of complications associated with compression of the subclavian artery, the operations consisted of the resection of the first rib and accessory osseous and muscular pathological elements using supraclavicular and/ infraclavicular approach with implantation of the vascular bypass were performed. The therapy results were estimated with the use of The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire of The American Academy of Orthopedic Surgeons.
Results: Where there were venous complications, thrombolytic therapy was successful in all cases - the restoration of complete patency was obtained. In all patients the first rib was resectioned via the transaxillary approach. The DASH questionnaire revealed the full return of upper limb function in most of patients. In cases of upper limb ischemia the improvement of blood flow was obtained after a subclavian-brachial bypass implantation (5 patients). In this group the DASH score showed return to full activity. In cases subclavian artery aneurysm surgery (9 patients), the DASH scale revealed a worsening of limb function 4 patients during the follow-up period.
Conclusions: The optimal therapy of vascular complications is multimodal treatment (thrombolysis reconstructive vascular procedure with decompressive surgery). The decompression of neurovascular bundle in vascular TOS should include a first rib resection in each case.
Material and methods: An investigation of 37 patients treated in the Department of Vascular, General and Transplantological Surgery of the Wroclaw Medical University for vascular complications of the TOS (Paget-Schroetter syndrome in 23 patients as well as upper limb ischemia and/or the subclavian artery aneurysm in 14 patients) was performed. In the case of venous thrombosis the treatment consisted of thrombolytic therapy (mainly recombinant tissue-type plasminogen activator - rt-PA), the use of anticoagulation (also oral anticoagulants) and decompressive procedures that included transaxillary first rib resection and the other surgical procedures that excise different anomalies in the region of the thoracic outlet. In cases of complications associated with compression of the subclavian artery, the operations consisted of the resection of the first rib and accessory osseous and muscular pathological elements using supraclavicular and/ infraclavicular approach with implantation of the vascular bypass were performed. The therapy results were estimated with the use of The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire of The American Academy of Orthopedic Surgeons.
Results: Where there were venous complications, thrombolytic therapy was successful in all cases - the restoration of complete patency was obtained. In all patients the first rib was resectioned via the transaxillary approach. The DASH questionnaire revealed the full return of upper limb function in most of patients. In cases of upper limb ischemia the improvement of blood flow was obtained after a subclavian-brachial bypass implantation (5 patients). In this group the DASH score showed return to full activity. In cases subclavian artery aneurysm surgery (9 patients), the DASH scale revealed a worsening of limb function 4 patients during the follow-up period.
Conclusions: The optimal therapy of vascular complications is multimodal treatment (thrombolysis reconstructive vascular procedure with decompressive surgery). The decompression of neurovascular bundle in vascular TOS should include a first rib resection in each case.
Keywords: Paget-Schroetter syndromesubclavian artery aneurysmlimb ischemiafirst rib resection
