Thoracic Outlet Syndrome Stephan Etheredge, Bruce Wilbur, and Ronald - - PowerPoint PPT Presentation

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The Management of Thoracic Outlet Syndrome: Acute

4/14/2016

Charles Eichler MD

Professor, Department of Surgery Division of Vascular and Endovascular Surgery University of California San Francisco

Disclosures

None relevant to this discussion

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Thoracic Outlet Syndrome

Stephan Etheredge, Bruce Wilbur, and Ronald J. Stoney

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Am J Surg 1979, Vol 138, 175-182

Venous TOS

Mechanical Compression or

• cclusion of the subclavian vein
• Thrombotic or nonthrombotic
• AKA Paget-Schroetter Syndrome
• r Effort Thrombosis

Costoclavicular Space Pathology

• Between Clavicle and First rib
• Between the anterior scalene

muscle and the subclavius muscle Acute

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Non occlusive:

• Intermittent, positional, arm discoloration, swelling and aching
• Elicited by exercise or arm elevation

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Neutral position Abduction, external rotation, head toward the affected side

Thrombotic (Most common)

• Sudden onset
• Aching, swelling, heaviness, bluish discoloration
• History of vigorous exercise
• Visible superficial collateral veins shoulder/chest wall

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IMAGING

Duplex Ultrasound Venography

• Diagnostic and

therapeutic Axial Imaging

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Provocative views are essential to make the diagnosis

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VTOS Clinical Goals

Eliminate Symptoms Prevent long-term disability Avoid the need for long term anticoagulation

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Contemporary treatment of VTOS

Acute Subclavian Vein Thrombosis

• 1. Restoration of venous patency
• 1. Thrombolysis
• 2. Elimination of extrinsic compression
• 1. First rib resection and venolysis
• 3. Correction of venous stenosis
• 1. Balloon angioplasty
• 2. Stents
• 3. Surgical vein reconstruction

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Anticoagulation alone does not work

Original standard of care Poor outcomes

• Persistent vein occlusion 78%
• Persistent symptoms 41-91%
• Permanent disability 39-68%

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Hughes 1949, Tilney 1970, Adams and DeWeese 1971, Becker 1991, Montreal 1991, AbuRahma 1991

What about if they have spontaneo us VTOS?

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A substantial number of patients will remain symptomatic based on clinical reporting or by ultrasonographic grade Scores from an 11-point numerical rating scale are plotted against ratings on a 6-point descriptive scale. Grade 0, normal flow; grade 1, moderate obstruction; grade 2, severe obstruction or occlusion of the axillary– subclavian vein.

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Contemporary treatment of TOS

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Contemporary outcomes for 1st rib resection for VTOS

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Author # Approach Patency Schneider 2015 33 IC 91% (PP) Molena 2007 97 IC 100% (PA) Schneider 2004 25 IC 92% (PP) Azakie 1998 20 SC 100% (Clinical) DeLeon 2009 67 TA 96% (PP) Urschel 2000 199 TA 95% (Clinical)

PP primary patency, PA primary assisted patency

Ongoing controversies: Timing of Surgery

Immediate or delayed Delayed to allow resolution of inflammation

• Re-thrombosis rate of 6% to 18% during waiting period

(Adams 1971, Machleder 1993, Hurlbert 1995)

Immediate operative decompression safe and effective

(Angle 2001, Schneider 2004, Melby 2008)

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Focusing the surgical approach to TOS

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• Supraclavicular
• Paraclavicular
• NTOS
• Arterial TOS
• Infraclavicular
• VTOS

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Potential Advantages of Infraclavicular Approach

Direct access (to vein within the costoclavicular space) Focused approach (minimizes exposure of brachial plexus, subclavian artery, & thoracic duct) Preserve supraclavicular and axillary venous collateral pathways Ability to access the central veins using transmanubrial extension for vein reconstruction

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Adjunctive Endovascular Procedures

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Intraoperative venography PTA ± stent

Adjunctive Surgical Procedures

Saphenous vein patch Cryopreserved aortic homograft ± arteriovenous fistula

Any venous defect must be addressed during the operation Postoperative anti-coagulation

Depends. If on completion venogram following the 1st rib resection, the vein looks very good with no residual stenosis consider no anticoagulation Otherwise, three to six months of anti-coagulation To anti-coagulate or not to anti-coagulate

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Conclusions

Thrombolysis followed by 1st rib resection is the current standard of care for patients with VTOS and acute subclavian vein thrombosis Focused infraclavicular 1st rib resection is safe, effective, and provides potential advantages for the treatment of VTOS Early identification and treatment leads to the best outcomes Patients presenting with subacute or chronic thrombosis do not do as well but may benefit from 1st rib resection and anticoagulation

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Thank You For Your Attention