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Outcomes of Surgical Paraclavicular Thoracic Outlet Decompression
Ali Azizzadeh1, Mohammad A. Toliyat1, Kristofer M. Charlton-Ouw1, Monir Hossain2, Anthony L. Estrera1, Sheila M. Coogan1, Hazim J. Safi1.
1UT Cardiothoracic and Vascular Surgery, Houston, TX, USA, 2UTHealth Center for Clinical and Translational Sciences, Houston, TX, USA.

OBJECTIVE: Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery resulting in neurogenic (N), venous (V), and arterial (A) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of surgical decompression for TOS.
METHODS: A retrospective review of medical records for patients who underwent surgical decompression for TOS at a newly established center was performed. Primary outcomes were assessed according to Derkash’s classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and length of stay.
RESULTS: From 8/2004 to 6/2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 males) with thoracic outlet syndrome. The mean age was 36.5 years (range 15 - 68). Bilateral decompression was performed on 4 patients. The TOS types were neurologic (n=19), venous (n=16), and arterial (n=5). The presenting symptoms were pain (83%), numbness (67.5%), swelling (57.5%), fatigue (52.5%), weakness (50%), coolness (32.5%), headache (25%), and ulceration (5%). A previous history of trauma was present in 22.2%. Two patients presented with recurrent symptoms after previous first rib resection at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients with NTOS completed a trial of physical therapy prior to surgery. All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and partial (52.5%) or complete (35%) first rib removal. Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow up. Two patients with incomplete relief of symptoms after paraclavicular decompression underwent pectoralis minor decompression. There was no mortality. Complications included pleural effusion requiring evacuation (n=4), neuropraxia (n=1), and lymph leak (n=1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean length of stay was 4.4 days. Mean follow-up was 10.3 months (range 0.2 - 57.1).
CONCLUSIONS: In our experience, surgical paraclavicular decompression can provide safe and effective relief of neurological, venous, and arterial TOS symptoms. Functional outcomes were excellent or good in the majority of patients with minimal complications.


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