Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 346-350

Arterial thoracic outlet syndrome – The need for early detection and surgical correction and how to do subclavian artery repair without resection

Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, India

Correspondence Address:
Sekar Natarajan
Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_99_20

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Objective: Arterial compression at the thoracic outlet is rarely diagnosed before embolization occurs. Decompression, embolectomy, and resection of the subclavian artery and interposition graft repair is the most common method of treatment. This is a retrospective analysis of a single surgeon experience with subclavian artery repair without resection for arterial thoracic outlet syndrome. Materials and Methods: Sixty limbs underwent surgery for arterial compression at the thoracic outlet in 57 patients over the last 29 years (1989–2018). There were 24 males and 33 females. The age group varied from 10 to 60 years. Thrombointimectomy and repair of the subclavian artery were done on 54 of the 57 symptomatic limbs. Three patients underwent prophylactic decompression of the thoracic outlet on the contralateral asymptomatic side. Results: Fifty-two patients had complete cervical rib, two had abnormal first rib, and three patients had fracture clavicle with nonunion. Fifteen patients presented with severe rest pain and pregangrenous changes in the finger tips. All the rest presented with ischemic changes of varying degrees in the upper limb. The duration of symptoms ranged from 2 to 300 days. All patients underwent decompression of the thoracic outlet in the form of scalenectomy and cervical rib or first rib resection. Thrombointimectomy and repair of the poststenotic dilatation without resorting to resection were done in 54 limbs. Only three patients required resection of the artery. One patient had end-to-end anastomosis and two others had interposition grafts. In addition, 43 patients had additional transbrachial embolectomy to clear the distal artery. Two patients had cervicodorsal sympathectomy. No patient underwent major amputation, but two patients required finger amputation. Palpable wrist pulse could be achieved in 45 patients. Patients were followed for an average of 2 years. Palpable pulse disappeared at 6-month follow-up in four patients. These four and another three patients with palpable pulse and the remaining 12 patients with no wrist pulse continued to have minor ischemic symptoms in the fingertips. Long-term follow-up did not reveal any aneurysm or stenosis at the subclavian repair site. Conclusion: Cervical rib though a congenital condition can remain asymptomatic till a later age. Arterial compression is rarely diagnosed before embolisation occurs. The distal artery may not be completely cleared of thrombi, and about 30% of the patients continue to suffer from ischemic symptoms even after successful surgery. Hence, all patients with complete cervical rib should be investigated and followed up with duplex scan for evidence of arterial compression. They should be advised prophylactic decompression when they develop duplex evidence of arterial compression. Intimectomy and subclavian artery repair produce good long-term results, and unnecessary resection of the subclavian artery should be avoided.

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