The Evolving Role Of Endovascular Therapy In The Management Of Arterial Thoracic Outlet Syndrome
Joe L. Pantoja, MD, David Rigberg, MD, Hugh Gelabert, MD.
University of California Los Angeles, Los Angeles, CA, USA.
OBJECTIVES: Over the past three decades, Vascular Surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by Vascular Surgeons and outcomes after both endovascular and open repair of the subclavian artery.
METHODS: We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases. For comparison, cases were divided into two equal time periods, 1986-2002 (P-1) versus 2003-2019 (P-2), and by treatment modality, open versus endovascular. Clinical presentation, outcomes, and the involvement of Vascular Surgeons in endovascular therapy were compared between the groups.
RESULTS: Out of 2,200 thoracic outlet syndrome cases, 45 patients (26 P-1, 19 P-2) underwent 49 operations (27 P-1, 22 P-2) for ATOS. 43 patients (95%) presented with acute limb-threatening ischemia. In all cases, the diagnosis of ATOS was confirmed with arteriography. Thrombolysis was done in 17 (38%). In P-1, Vascular Surgeons performed 4% of the catheter-based angiograms and 0% of thrombolysis. In P-2, Vascular Surgeons performed 47% of the angiograms, 55% of thrombolysis, and 100% of stent grafting. All patients underwent trans-axillary first rib and cervical rib resection. Subclavian artery pathology included 18 (37%) aneurysms and 31 (63%) stenotic lesions. Aneurysm repairs were either open reconstruction or stent graft repairs. Compared to open reconstruction, endovascular procedures took less time (258 versus 312 mins), incurred lower estimated blood loss (120 vs 192 mL), and shorter length of stay (2.8 vs 4.2 days). These differences did not achieve statistical significance. Over a mean follow-up time of 4.2 years, 98% of patients were able to resume work or school. Residual symptoms persisted in 8 patients including post-ischemic neuropathy and claudication. QuickDASH (Disabilities of the Arm, Shoulder, and Hand) scores reduced from 34.4 to 8.8 and somatic pain scores reduced from 2.5 to 0.5.
CONCLUSIONS: The role of endovascular therapy in management of ATOS has expanded over three decades. The combination of thrombolysis, angioplasty and stent graft repair of aneurysms has reduced average operating time, blood loss, and length of stay. Outcome of endovascular interventions were equivalent to open surgical technique with less morbidity and excellent results.
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