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ObjectiveThoracic outlet syndrome (TOS) has life-changing impacts on young athletes. As the level of competition increases between the high school (HS) and collegiate (CO) stage of athletics, the impact of TOS may differ. Our objective is to compare surgical outcomes of TOS in HS and CO athletes.MethodsThis was a retrospective review of HS and CO athletes within a prospective surgical TOS database. The primary outcome was postoperative return to sport. Secondary outcomes were resolution of symptoms assessed with somatic pain scale (SPS), QuickDASH, and Derkash scores. Categorical and continuous variables were compared using χ2 and analysis of variance, respectively. Significance was defined as P < .05.ResultsThirty-two HS and 52 CO athletes were identified. Females comprised 82.9% HS and 61.5% CO athletes (P = .08). Primary diagnoses were similar between groups (venous TOS: HS 50.0% vs CO 42.3%; neurogenic TOS: 43.9% vs 57.7%; pectoralis minor syndrome: 6.3% vs 0.0%) (P = .12). Pectoralis minor syndrome was a secondary diagnosis in 3.1% and 3.8% of HS and CO athletes, respectively (P = 1.00). The most common sports were those with overhead motion, specifically baseball/softball (39.3%), volleyball (12.4%), and water polo (10.1%), and did not differ between groups (P = .145). Distribution of TOS operations were similar in HS and CO (First rib resection: 94.3% vs 98.1%; scalenectomy: 0.0% vs 1.9%, pectoralis minor tenotomy: 6.3% vs 0.0%) (P = .15). Operating room time was 90.0 vs 105.3 minutes for HS and CO athletes, respectively (P = .14). Mean length of stay was 2.0 vs 1.9 days for HS and CO athletes (P = .91). Mean follow-up was 6.9 months for HS athletes and 10.5 months for CO athletes (P = .39). The majority of patients experienced symptom resolution (HS 80.0% vs CO 77.8%; P = 1.00), as well as improvement in SPS, QuickDASH, and Derkash scores. Return to sport was similar between HS and CO athletes (72.4% vs 73.3%; P = .93). Medical disability was reported in 100% HS athletes and 58.3% CO athletes who did not return to sport (P = .035).ConclusionsDespite increased level of competition, HS and CO athletes demonstrate similar rates of symptom resolution and return to competition. Of those that did not return to their sport, HS athletes reported higher rates of medical disability as a reason for not returning to sport compared with CO athletes.

Abstract Background Large mediastinum tumors invading the thoracic outlet have consistently been a challenge in thoracic surgery. Due to the large size of the tumor and its proximity to many important tissues, appropriate surgical approaches are crucial for a successful surgery. Case presentations Here, we present a case of a large neurilemmoma that invaded the thoracic outlet that was resected by a supraclavicular-median sternotomy approach. The case was a 58-year-old woman with a large mass in the right chest cavity that had invaded the thoracic outlet. The preoperative biopsy showed a blood clot with a few fibrous connective tissues covered by a single layer of flat epithelium. There was insufficient evidence to diagnose the mass as a tumor, and imaging examinations suggested a diagnosis of solitary pleural fibroma. For good exposure of the cranial and caudal aspects of the large mass, we devised a median sternotomy combined with a supraclavicular approach and safely achieved complete resection. The patient recovered well and experienced no severe complications or functional restrictions of the upper extremity. The postoperative pathology diagnosis was a neurilemmoma. Conclusions The supraclavicular-median sternotomy approach could be an optional approach for the complete resection of large mediastinal tumors invading the thoracic outlet.

Background: Large mediastinum tumors invading the thoracic outlet have consistently been a challenge in thoracic surgery. Due to the large size of the tumor and its proximity to many important tissues, appropriate surgical approaches are crucial for a successful surgery. Case presentations: Here, we present a case of a large neurilemmoma that invaded the thoracic outlet that was resected by a supraclavicular-median sternotomy approach. The case was a 58-year-old woman with a large mass in the right chest cavity that had invaded the thoracic outlet. The preoperative biopsy showed a blood clot with a few fibrous connective tissues covered by a single layer of flat epithelium. There was insufficient evidence to diagnose the mass as a tumor, and imaging examinations suggested a diagnosis of solitary pleural fibroma. For good exposure of the cranial and caudal aspects of the large mass, we devised a median sternotomy combined with a supraclavicular approach and safely achieved complete resection. The patient recovered well and experienced no severe complications or functional restrictions of the upper extremity. The postoperative pathology diagnosis was a neurilemmoma. Conclusions: The supraclavicular-median sternotomy approach could be an optional approach for the complete resection of large mediastinal tumors invading the thoracic outlet. [ABSTRACT FROM AUTHOR]

BackgroundPerioperative care after surgery for thoracic outlet syndrome (TOS) involves multimodal pain control. Pain catheters with bupivacaine infusion are a modality to minimize perioperative narcotic use. Our study aims to compare surgically placed pain catheters (SP) with erector spinae pain catheters (ESP) placed by the anesthesia pain service.MethodsRetrospective review of a prospectively maintained surgical TOS database identified patients undergoing transaxillary first rib resection (FRR) who had either SP or ESP placed for pain control. Patients were matched for age and gender. Data collected included demographics, operative details, and perioperative pain medication use. Narcotic pain medication doses were converted to milligram morphine equivalents (MME) for comparison between groups. Pain medications were collected for several time points: intraoperatively, for each post-operative day (POD), and for the entire hospital stay.ResultsEighty-eight total patients were selected for comparison: 44 patients in the SP and ESP groups. Patients in each group did not differ with regards to age, BMI, gender, diagnosis, or comorbidities. There were no differences in preoperative narcotic use, preoperative pain score, or QuickDASH score. All patients underwent FRR. Concurrent cervical rib resection was performed in 6.8% SP and 6.8% ESP patients (p=1.00), pectoralis minor tenotomy in 34.1% SP and 29.5% ESP patients (p=0.65), and venogram in 31.8% SP and 31.8% ESP patients (p=1.00). Mean OR time was 90.0 minutes in SP and 105.3 minute in ESP cases (p=0.15). Mean length of stay was 1.9 days for SP and 1.8 days for ESP patients (p=0.56). There were no significant differences in intraoperative narcotics dosing in MME (SC: 22.1 vs ESP: 25.3, p=0.018). On POD 0, there were no differences in total narcotics dosing (MME) (SC: 112.0 vs ESP: 100.7, p=0.59), or in the use of acetaminophen, NSAIDS, or muscle relaxants. A similar trend in narcotics dosing was observed on POD 1 (SP: 58.6 vs ESP: 69.7, p=0.43), and POD 2 (SP: 23.5 vs ESP: 71.3, p=0.23). On POD 1, there was a higher percentage of SP patients taking NSAIDs (63.6% vs 40.9%, p=0.024), however, this difference was not observed on POD 2. There were no differences in acetaminophen or muscle relaxant use on POD 1 or 2. Total hospital stay MME was similar between groups (SC: 215.9 vs ESP: 250.9, p=0.23) CONCLUSION: Pain catheters with bupivacaine infusions are helpful adjuncts in postoperative pain control after FRR for TOS. This study compares SP to ESP, and demonstrates no difference in narcotics use between SP and ESP groups. SC should be used for pain control in facilities which do not have an anesthesia pain service available for ESP placement.

A 59-year-old woman presented with dizziness and numbness of her left upper limb. Computed tomography (CT) angiography revealed an occlusion of the subclavian artery at its origin, leading to a diagnosis of subclavian steal syndrome. She was treated with percutaneous angioplasty and stenting; however, her symptoms did not improve. CT angiography of the arm in the elevated position revealed subclavian artery stenosis at the costoclavicular space, and the diagnosis was neurogenic thoracic outlet syndrome (TOS). First-rib resection was performed, and the symptoms disappeared immediately after surgery. TOS should be considered when symptoms persist despite subclavian steal syndrome treatment. Physical examination and CT imaging with the arm elevated aid in diagnosing TOS.

ObjectiveWe compared the functional outcomes among adolescent athletes with venous thoracic outlet syndrome (VTOS) and neurogenic TOS (NTOS) after thoracic outlet decompression.MethodsWe performed a single-institution retrospective review of a prospective database of adolescent athletes (aged 13-19 years) from June 1, 1996 to December 31, 2021 who had undergone operative decompression for TOS. The demographic data, preoperative symptoms, operative details, and postoperative outcomes were compared. The primary outcome was the postoperative return to sport. The secondary outcomes included symptom resolution and assessment of the somatic pain scale, QuickDASH, and Derkash scores. The Fisher exact test and t test were used to evaluate the categorical and continuous variables, respectively. A logistic regression model was constructed to adjust for the influence of preoperative factors and return to sport.ResultsA total of 60 patients (40.0% with VTOS and 60.0% with NTOS) were included. The average age of the VTOS patients was 17.2 years vs 16.6 years for the NTOS patients (P = .265). The NTOS patients were more likely to be female (88.9% vs 62.5%; P = .024). The NTOS patients had more frequently presented with pain (97.2% vs 70.8%; P = .005), paresthesia (94.4% vs 29.1%; P = .021), and weakness (67.7% vs 12.5%; P = .004) but had less often reported swelling (25.0% vs 95.8%; P < .001). At presentation, the NTOS patients had also reported a longer symptom duration (17.7 months vs 3.1 months; P < .001). Transaxillary first rib resection with subtotal scalenectomy was performed for 100% of the VTOS patients and 94.4% of the NTOS patients undergoing cervical rib resection (2.8%) or scalenectomy alone (2.8%). Additionally, 11.1% of the NTOS patients had undergone combined first rib resection and cervical rib resection. For the VTOS patients, postoperative venography showed patent subclavian veins in 27.8%. In addition, 44.4% had required venoplasty, 16.8% had required thrombolysis, and 11% were chronically occluded. No significant differences were found in blood loss, operative time, or length of stay between the groups. No surgical complications occurred. The average follow-up was 6.3 months. Significant differences were found between the VTOS and NTOS groups for the pre- and postoperative somatic pain scale, QuickDASH, and Derkash scores. Complete symptom resolution had occurred in 83.3% of the VTOS and 75% of the NTOS patients (P = .074). No statistically significant difference in the return to sport was observed between the two groups (VTOS, 94.4%; vs NTOS, 73.9%; P = .123). Of the NTOS patients, 10.0% had had other concomitant injuries and 5.0% had had medical conditions that had precluded their return to sport. Logistic regression found no significant relationship between the preoperative somatic pain scale score, QuickDASH score, or duration of symptoms and the return to sport.ConclusionsAdolescent athletes with VTOS and NTOS can have good functional outcomes, and most will be able to return to sport after surgery. Greater initial symptom severity and concomitant injuries were observed in adolescents with NTOS. Of those who had not returned to sport postoperatively, three of seven had had unrelated health issues that had prevented their return to sport.

ObjectiveManagement of Paget-Schroetter syndrome (PSS) with first rib resection (FRR) and venoplasty is successful in re-establishing subclavian vein (SCV) patency in most cases. However, in cases with subacute or chronic venous occlusion, SCV patency may not be achieved. Thus, the role for FRR remains controversial in cases of subacute or chronic SCV occlusion. Our goal is to determine whether FRR is beneficial in PSS patients with subacute or chronic SCV occlusion.MethodsA prospectively maintained thoracic outlet syndrome (TOS) database was searched for patients undergoing FRR who were identified as having SCV occlusion on preoperative venography between 2012 and 2021. Preoperative and postoperative venous patency were determined by venography. Standardized functional outcomes were assessed using the Quick Disability Arm, Shoulder, Hand (QuickDASH-QDS) and Somatic Pain Scale (SPS) before and after FRR. The Derkash outcome score was recorded after FRR.ResultsOver the study period, 966 TOS operations were performed; of these, 401 were for venous TOS, and 33 patients were identified with subacute or chronic preoperative SCV occlusion verified by venography. The median age was 29 years, with 73% men. Eighteen patients had attempted thrombolysis; eight were performed at our institution, and ten performed at a referring facility. The median time from the symptom onset of SCV occlusion to FRR was 78 days for all patients. For the group that achieved venous patency after FRR, the time from SCV occlusion to FRR was 71 days, and it was 106 days for the group that remained occluded after FRR. All underwent postoperative venography and percutaneous attempt at SCV recanalization. Recanalization was successful in 64% (21) and unsuccessful in 36% (12). All patients experienced improvement in SPS and QDS. For all patients, the average SPS improved from 1.69 preoperatively to 0.25 postoperatively and the average QDS improved from 27.63 preoperatively to 10.19 postoperatively (P > .05). For patients who were successfully recanalized, the final SPS was 0.18 and the final QDS was 11.22 (P > .05). In patients who failed to achieve recanalization, the final SPS was 0.40 and the final QDS was 9.06 (P > .05). All postoperative Derkash outcome scores were excellent and good, with none fair or poor.ConclusionsIn patients with subacute or chronic preoperative SCV occlusion, surgical decompression and postoperative angioplasty resulted in re-establishing SCV patency in 64% of patients. Symptomatic patients clinically improve after surgical decompression regardless of whether venous patency is successfully re-established. These results indicate that symptomatic patients with PSS should be considered for TOS decompression even if their SCV is occluded in the subacute or chronic presentation.

Introduction: This study assesses the influence of inferior thoracic aperture dimensions on the outcomes of laparoscopic cholecystectomy for cholelithiasis. It aims to determine if the size of the thoracic outlet, akin to pelvic measurements in obstetrics, can predict surgical complexity and complications. Materials and Methods: In this prospective anatomical and clinical study, 32 patients who underwent laparoscopic cholecystectomy between April 2014 and December 2015 at Bursa Yuksek Ihtisas Research and Training Hospital were evaluated. Anteroposterior (AP) and laterolateral (LL) diameters of the inferior thoracic aperture were measured using CT or MRI. The study focused on dissection time and intraoperative blood loss, quantitatively. Results: Twenty-three of 32 patients (71.9%) were female, and 9 (28.1%) were male. The mean age of the patients was 57.97±16.11 years (min: 29; max: 85). The mean overall dissection time was 1,172.43±427.58 seconds (min: 550; max: 2,157), and the median amount of intraoperative hemorrhage was 6.5 cc (min: 1; max: 23). The mean LL diameter of the patients was 26.02±2.29 cm (min: 21.50; max: 31.50), and the median value of the AP diameter was found to be 11.35 cm (min: 9.40; max: 19.40). A positive relationship was found between the LL and AP diameters (r=0.574; p=0.001). There was a negative relationship between operational time and both LL and AP diameters (r=-0.418; p=0.017 and r=-0.405; p=0.022). Conclusion: Findings suggest that narrower thoracic apertures can prolong the standard 4-port-access laparoscopic cholecystectomy procedure. This study underscores the importance of measuring thoracic outlet diameters for anticipating surgical difficulty in general surgery, analogous to pelvic measurements in obstetrics. Such measurements could be pivotal in preoperative planning and in improving surgical outcomes. [ABSTRACT FROM AUTHOR]

Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access. [ABSTRACT FROM AUTHOR]

Selecting patients who will benefit from first rib resection for neurogenic thoracic outlet syndrome (nTOS) is made difficult by the variety of overlap symptoms with other musculoskeletal, neurogenic and psychological disease. A single diagnostic test is not available, and the diagnosis is typically made based on clinical findings and history. This case series assessed the utility of magnetic resonance imaging (MRI), with the patient's arm placed in a symptom provoking position above the head, as a component of diagnosis nTOS and selection of patients to offer surgery. Outcomes from first rib resection were assessed using the guidelines of The Society for Vascular Surgery for Thoracic Outlet Syndrome. The cases demonstrate that the loss of perineural fat signal on MRI of the brachial plexus with the arm in the provocative position is a useful tool for assessing patients who would benefit from first rib resection for nTOS. [ABSTRACT FROM AUTHOR]

Purpose: Venous steno-occlusive disease at the thoracic outlet affects up to 30% of the hemodialysis population [1] causing arm swelling and hemodialysis access dysfunction. Balloon angioplasty in this region can be of limited utility given the rigid compressive effect of surrounding musculoskeletal (MSK) structures. Outcomes of using the Viatorr endoprosthesis (Gore Viatorr TIPS Endoprosthesis, Gore, Flagstaff AR, USA, Viatorr ®) within this region to salvage the HD access in patients who presented with dialysis access dysfunction is presented. Methods: A retrospective chart review was performed of our tertiary and quaternary care hospital system. Hemodialysis patients were included in the study if they were using an upper extremity arteriovenous fistula or graft for access, had a Viatorr stent placed in the central (subclavian and/or brachiocephalic) veins, and had follow up. Results: A total of nine patients were identified to meet the inclusion criteria. Four interventions were due to refractory lesions of the subclavian or brachiocephalic veins, and the other five interventions were for hemodynamically significant lesions refractory to angioplasty alone, all resulting in access dysfunction. Primary patency ranged from 36-442 days (geometric mean 156.6 days, range 19-442 days). No stent fracture was identified on imaging at any point during follow-up of these patients out to a maximum of 2912 days (Average 837 days). Conclusions: The Viatorr stent graft used in the HD population for clinically significant lesions at the thoracic outlet (TO) showed no structural failures (fractures) in this cohort. [ABSTRACT FROM AUTHOR]

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2–4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis. [ABSTRACT FROM AUTHOR]

ObjectiveSpontaneous subclavian vein (SCV) thrombosis (Paget-Schroetter syndrome [PSS]) has been attributed to venous compression at the thoracic outlet and traditionally diagnosed using venography. Intravascular ultrasonography (IVUS) allows for a multidimensional view of vascular structures and might be more accurate in revealing venous compression. The goal of the present study was to compare venography and IVUS in patients presenting with PSS to assess the relative accuracy of each modality.MethodsPatients presenting for evaluation of PSS from 2013 to 2019 were evaluated for SCV compression using venography and IVUS. Venography and IVUS measurements of stenosis were performed of the index and contralateral limbs in both neutral and stress (arm overhead) positions. The IVUS data included the SCV diameters in the anteroposterior (AP) plane, craniocaudal (CC) plane, and cross-sectional area (CSA). Stenosis was reported as the percentage of reduction from a reference point (lateral margin of the first rib) for the venography and IVUS data.ResultsFor the 35 subjects, the average age was 35 years, 57% were women, 20% had presented with a documented pulmonary embolus, and 70% had initially been treated with thrombolysis. Venography demonstrated SCV occlusion in 3 patients (16%) with the index limb in the neutral position and in 18 patients (54%) with the limb in the stress position. The average stenosis in the index limbs was 41.5% (venography), and the average IVUS stenosis was 41.9% (CC), 61.8% (AP), and 74.5% (CSA; P < .05). A subset analysis revealed that in 10 of 35 patients (28%) in whom venography had identified no significant stenosis (average, 10%), IVUS had identified significant stenosis (33.5% CC, 54.3% AP, 68.7% CSA; P < .05).ConclusionsIVUS proved more sensitive than venography in detecting significant stenosis leading to SCV thrombosis. A reduction in the CSA was the most sensitive measure of stenosis. IVUS identified significant stenosis in patients in whom venography failed to do so. The greatest utility of IVUS is in the evaluation of patients with PSS in whom venography shows no evident compression.

Arterial thoracic outlet syndrome (aTOS) is rarely diagnosed in children. A 15-year-old boy with recent-onset claudication was found to have aTOS on investigation. Bony abnormality other than the cervical rib might also cause aTOS. Enhanced awareness of aTOS as a cause of vascular symptoms in children is warranted.

BackgroundThoracic outlet syndrome (TOS) is a pathological condition caused by a narrowing between the clavicle and first rib leading to a compression of the neurovascular bundle to the upper extremity. The incidence of TOS is probably nowadays underestimated because the diagnosis could be very challenging without a thorough clinical examination along with appropriate clinical testing. Beside traditional supra-, infraclavicular or transaxillary approaches, the robotic assisted first rib resection has been gaining importance in the last few years.MethodsWe conducted a retrospective cohort analysis of all patients who underwent robotic assisted first rib resection due to TOS at Lucerne Cantonal Hospital and then we performed a narrative review of the English literature using PubMed, Cochrane Database of Systematic Reviews and Scopus.ResultsBetween June 2020 and November 2021, eleven robotic assisted first rib resections were performed due to TOS at Lucerne Cantonal Hospital. Median length of stay was 2 days (Standard Deviation: +/– 0.67 days). Median surgery time was 180 min (Standard Deviation: +/– 36.5). No intra-operative complications were reported.ConclusionsRobotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.

A 59-year-old woman presented with dizziness and numbness of her left upper limb. Computed tomography (CT) angiography revealed an occlusion of the subclavian artery at its origin, leading to a diagnosis of subclavian steal syndrome. She was treated with percutaneous angioplasty and stenting; however, her symptoms did not improve. CT angiography of the arm in the elevated position revealed subclavian artery stenosis at the costoclavicular space, and the diagnosis was neurogenic thoracic outlet syndrome (TOS). First-rib resection was performed, and the symptoms disappeared immediately after surgery. TOS should be considered when symptoms persist despite subclavian steal syndrome treatment. Physical examination and CT imaging with the arm elevated aid in diagnosing TOS., Competing Interests: None., (© 2024 The Authors.)

A patient with recent thoracic outlet decompression surgery presented with acute dyspnea and was found by point-of-care ultrasound to have diaphragm dysfunction. This case highlights an unexpected cause of respiratory complaints in the outpatient setting discovered at the bedside, utilizing point-of-care ultrasound protocol.

Nuss procedure has become the treatment of choice in pectus excavatum mainly because of the excellent functional and cosmetic results. Despite the good results, several complications have been reported. The aim of this study is to describe a case of thoracic outlet syndrome (TOS) after Nuss procedure and review the management of such rare complication. A 15-year-old boy otherwise healthy was submitted to Nuss procedure, with no perioperative complications. Two-weeks later, the patient complained of right-hand paresthesia, progressive weakness of the right arm and coldness. After imaging and electromyography, TOS diagnosis was established. Removal of the bar was proposed but refused by the patient. Conservative management with rehabilitation exercising and nerve nourishing was initiated. At 7 months, the patient recovered arm and hand function. Abrupt structural changes of thoracic cavity with marked elevation of the upper chest induce nerve and vascular compression arousing a TOS and should be acknowledged as one potential complication of Nuss procedure. Conservative management can be an alternative treatment to bar removal, showing good results on functional recovery in early stages of compression.

Penetrating injuries to the neck present a unique challenge due to the confined space of the thoracic outlet for haemorrhage control and repair. This results in high mortality rates when the major vascular structures of the neck are transected, as well as potential neurological compromise. We present the case of a penetrating injury to the proximal subclavian artery from a broken angle grinder disc which is a unique mechanism of injury that can have fatal consequences. The patient described in this case underwent an emergent median sternotomy for proximal control of the brachiocephalic trunk and ligation of the right vertebral artery to facilitate a primary repair of the injured vessel segment. Post operatively the patient made a complete recovery with no central or peripheral neurologic deficits and requiring no further interventions. The key points from this case are that angle grinders pose a significant injury burden and early specialised medical attention should be sought, rapid control of the proximal neck vessels can be obtained via a median sternotomy and that the vertebral artery can be ligated in an emergent situation without neurological consequence.

Aim: To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome. Materials and methods: We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome. Results: There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed. Conclusions: Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition. [ABSTRACT FROM AUTHOR]

Background: Thoracic outlet syndrome (TOS) results from compression of neurovascular structures supplying the upper extremity as they exit the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. Objectives: Transaxillary (TA) and supraclavicular (SC) approaches are both widely utilized and deemed effective. Our objective was to review the outcomes for both approaches at our institution. Methods: A retrospective review was conducted on patients who underwent thoracic outlet decompression between 2010 and 2015. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected. Operative times, length of hospital stay, perioperative complications, and outcomes were also studied. Results: A total of 82 thoracic outlet decompression procedures were performed during the study period: 42% neurogenic TOS, 46% venous TOS, and 12% arterial TOS. In total, 49% underwent TA approach and 51% underwent SC approach. Adjunct procedures were performed in 13% of patients. There were no significant differences in average operative time (151.3 ± 54.1 minutes versus 126.1 ± 36.1 minutes, P = .11) or hospital stay (2.3 ± 1.9 days versus 2.4 ± 1.4 days, P = .23) between both groups, respectively. Minor complications were seen in 6% of patients with no significant difference in both groups, whereas 6% had major complications. No perioperative or 30-day mortalities were observed. In total, 49% of patients had complete resolution of symptoms, 46% had partial improvement, and 5% had no improvement. There was no difference in symptom resolution between either group. Conclusions: TA and SC approaches are equally safe and effective for the treatment of TOS. SC decompression allows for adjunct procedures and vascular reconstructions. [ABSTRACT FROM AUTHOR]

Objectives: Scarring from prior bypass surgery and irradiation may compromise revascularization options in critical ischemia due to underlying occlusive disease. Occlusive disease of the axillo-brachial artery is particularly difficult to revascularize under such hostile conditions.Method: We present a case of a 58-year-old woman presenting with a painful, pulseless, and cool left upper extremity. The patient had a known history of left upper extremity occlusive disease which was managed by subclavian-axillary artery stenting with re-occlusion and subsequent extra-anatomic left carotid-to-proximal brachial artery prosthetic bypass, which was complicated by stroke. The patient had a history of left mastectomy, axillary node dissection, and external beam radiation therapy. When considering revascularization options, the combination of post-radiation changes and scarring of the conventional operative zones for revascularization posed a high risk for complications. We describe a novel approach for such revascularization, where the inflow source was the terminal brachiocephalic artery, outflow to the upper left brachial artery, with anatomic intrathoracic-to-axillary tunneling through the thoracic outlet after verifying the lack of dynamic extrinsic compression at that level.Result: The procedure resulted in resolution of the symptoms and the patient continued to do well 2 years later.Conclusion: This case shows that anatomic tunneling through the thoracic outlet can be a viable option for upper extremity revascularization when hostile conditions preclude other anatomic tunneling routes or extra-anatomic options. [ABSTRACT FROM AUTHOR]

Background: Surgical treatment of thoracic outlet syndrome (TOS) is necessary when non-surgical treatments fail. Complications of surgical procedures vary from short-term post-surgical pain to permanent disability. The outcome of TOS surgery is affected by the visibility during the operation. In this study, we have compared the complications arising during the supraclavicular and the transaxillary approaches to determine the appropriate approach for TOS surgery. Methods: In this study, 448 patients with symptoms of TOS were assessed. The male-to-female ratio was approximately 1:4, and the mean age was 34.5 years. Overall, 102 operations were performed, including unilateral, bilateral, and reoperations, and the patients were retrospectively evaluated. Of the 102 patients, 63 underwent the supraclavicular approach, 32 underwent the transaxillary approach, and 7 underwent the transaxillary approach followed by the supraclavicular approach. Complications were evaluated over 24 months. Results: The prevalence of pneumothorax, hemothorax, and vessel injuries in the transaxillary and the supraclavicular approaches was equal. We found more permanent and transient brachial plexus injuries in the case of the transaxillary approach than in the case of the supraclavicular approach, but the difference was not statistically significant. Persistent pain and symptoms were significantly more common in patients who underwent the transaxillary approach (p＜0.05). Conclusion: The supraclavicular approach seems to be the more effective technique of the two because it offers the surgeon better access to the brachial plexus and a direct view. This approach for a TOS operation offers a better surgical outcome and lower reoperation rates than the transaxillary method. Our results showed the supraclavicular approach to be the preferred method for TOS operations.

Objetivo El ligamento de Caldani o córacoclavicular medial (LCCM) ha sido estudiado anatómicamente pero no hemos hallado mención alguna sobre su identificación imagenológica. El objetivo del presente trabajo es presentar una técnica original de resonancia magnética que hemos desarrollado para identificarlo, y describir las imágenes correspondientes. Materiales y Métodos Se incluyeron en el protocolo de investigación a 7 voluntarios sin patología de hombro conocida. Se utilizó un Resonador Magnético PHILLIPS INGENIA de una intensidad de campo magnético de 1.5 Tesla Versión 4.1, diámetro de Gantry (túnel del resonador) de 70 cm, bobina Sense específica para Hombro de 8 canales con imágenes de alta resolución. Se realizaron las secuencias de búsqueda del ligamento en tres planos. Resultados El LCCM fue identificado en todos los casos, extendiéndose oblicuamente desde la apófisis coracoides a la clavícula coincidiendo con las descripciones de la bibliografía anatómica consultada. Presentó una señal hipointensa en todas las secuencias, indicando el poco espacio entre fibras y correspondiendo a tejido colágeno compacto. Su longitud promedio fue de 41,15mm (entre 34mm y 47mm, desvío standard de 4,40). El espesor promedio fue de 2,11mm (entre 1,3mm y 3,2mm, desvío standard de 0,66). Conclusión El LCCM puede ser observado en imágenes de resonancia magnética mediante la técnica original que describimos. La posibilidad de localizar y observar el LCCM mediante resonancia magnética abre las puertas al estudio del mismo en futuras investigaciones, no sólo de compresiones neurovasculares sino también en lesiones traumáticas acromioclaviculares, especialmente en las tipo V de la clasificación de Rockwood.

Arterial thoracic outlet syndrome (aTOS) is rarely diagnosed in children. A 15-year-old boy with recent-onset claudication was found to have aTOS on investigation. Bony abnormality other than the cervical rib might also cause aTOS. Enhanced awareness of aTOS as a cause of vascular symptoms in children is warranted. [ABSTRACT FROM AUTHOR]

A patient with recent thoracic outlet decompression surgery presented with acute dyspnea and was found by point-of-care ultrasound to have diaphragm dysfunction. This case highlights an unexpected cause of respiratory complaints in the outpatient setting discovered at the bedside, utilizing point-of-care ultrasound protocol. [ABSTRACT FROM AUTHOR]

The thoracic outlet syndrome is characterized by compression of the brachial plexus or subclavian vessels due to anatomical alterations of the thoracic cavity. Vascular presentation is rare and includes thromboembolism and edema in the upper limb, and the diagnosis is often elusive due to its rarity. In this case, we describe a vascular thoracic outlet syndrome presentation whose diagnosis through angiography was achieved after a mechanical thrombectomy. We report a 43-year-old female patient with pain in the right upper limb, accompanied by edema and mild violet discoloration, without risk factors for hypercoagulability, with D-dimer levels within normal values. Mechanical thrombectomy with AngioJET was performed via an endovascular approach, with the extraction of multiple clots, confirming the presence of thoracic outlet syndrome as the underlying cause of the current condition. Venous thoracic outlet syndrome is a challenging entity to diagnose; however, it should be considered in cases of deep vein thrombosis of the subclavian vein and confirmed by angiography after a thrombectomy. • We describe a vascular thoracic outlet syndrome presentation • Mechanical thrombectomy using AngioJET revealed thoracic outlet syndrome as the root of her symptoms. • This condition can manifest as deep vein thrombosis in the subclavian vein, and its rarity makes it difficult to diagnose. [ABSTRACT FROM AUTHOR]

Congenital anatomic anomalies and variations are frequent in the thoracic outlet and may be associated with clinical symptoms. Arterial thoracic outlet syndrome (TOS) is characterized by subclavian artery compression and vascular pathology, almost always in the presence of a bony abnormality. We describe here a patient with arterial thromboembolism following a fall on the outstretched arm, who was found to have subclavian artery stenosis and post-stenotic dilatation in the absence of a bony abnormality. Surgical exploration revealed a previously undescribed anomaly in which the subclavian artery passed through the costoclavicular space in front of the anterior scalene muscle, where it was subject to bony compression between the first rib and clavicle. Successful treatment was achieved by scalenectomy, first rib resection and interposition bypass graft reconstruction of the affected subclavian artery. This newly acknowledged anatomical variant adds to our understanding of the diverse factors that may contribute to development of TOS. [ABSTRACT FROM AUTHOR]

Purpose: Cervicothoracic paravertebral neoplasms extending into the mediastinum pose a surgical challenge due the complex regional anatomy, their biological nature, rarity and surgeon's unfamiliarity with the region. We aim to define a surgical access framework addressing the aforementioned complexities whilst achieving oncological clearance.Methods: We carried out a retrospective review of 28 consecutive patients operated in two tertiary referral centres between 1998 and 2015. Pathology was located paravertebrally from C6 to T4 with superior mediastinum invasion. Patients were operated jointly by a spinal and a thoracic surgeon.Results: Tumours were classified according to subclavian fossa involvement as anteromedial, anterolateral and posterior and according to histology in benign nerve sheath tumour group (n = 10) and malignant bone or soft tissue tumours (n = 18). Three surgical routes were utilised: (1) median sternotomy (n = 11), (2) anterior cervical transsternal approach (n = 7) and (3) high posterolateral thoracotomy (n = 10). Resection was en bloc with wide margins in 22 cases, marginally complete in 3 and incomplete in 3. Complications included Horner's syndrome (n = 3), infection (n = 2) and transient neurological deficit (n = 4). In the nerve sheath tumour group, no recurrence or reoperation took place with a median follow-up of 4.5 years. In the malignant bone and soft tissue group, 96% of the patients were alive at 1 year, 67% at 2 years and 33% at 5 years. No vascular injuries or operative related deaths were observed.Conclusions: Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relationship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides minimal morbidity/maximum resection and satisfactory oncological outcomes. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]