30-year Single Center Experience With Arterial Thoracic Outlet Syndrome
Grayson S. Pitcher, M.D., Bernardo C. Mendes, M.D., Fahad Shuja, M.B.B.S., Randall R. DeMartino, M.D., Gustavo S. Oderich, M.D., Thomas C. Bower, M.D., Manju Kalra, M.B.B.S., Jill J. Colglazier, M.D..
Mayo Clinic, Rochester, MN, USA.
Arterial thoracic outlet syndrome (ATOS) is rare. We present our 30-year experience with management of ATOS at a high-volume referral center.
A retrospective review of all patients who underwent primary operative treatment for ATOS from 1988 to 2018 was performed. ATOS was defined as subclavian artery pathology caused by extrinsic compression from a bony abnormality within the thoracic outlet.
Forty-one patients (forty-five limbs) underwent surgical treatment for ATOS with a median age of 46 (IQR 34-58). Chronic symptoms (>6 weeks) were found in 69% (n = 31). Thirteen patients (29%) presented with acute limb ischemia (ALI) requiring urgent brachial artery thromboembolectomy (BAT) in nine and catheter-directed thrombolysis and thrombectomy (CDT) in four. All patients underwent thoracic outlet decompression. 69% (n = 31) required subclavian artery reconstruction. There were no perioperative deaths and only one major adverse limb event. Patients with ALI had staged thoracic outlet decompression after initial BAT or CDT at a median of 23 days (IQR 11-140). Eight had a recurrent thromboembolic event prior to thoracic outlet decompression subsequently requiring nine BATs and one CDT. Delayed thoracic outlet decompression greater than 14 days was associated with an increased risk of recurrent embolization or thrombosis (p = 0.024). Thirty-two patients had follow-up at a median of 13 months (IQR 5-36) with a subclavian artery/graft patency of 94%. Five (14%) had chronic upper extremity pain and five (14%) had weakness. Preoperative forearm or hand pain and brachial artery occlusion were strongly associated with chronic pain (p = 0.037 and p = 0.033) and weakness (p = 0.032 and p = 0.018). Eleven patients who presented with ALI had follow-up after thoracic outlet decompression at a median of 6 months (IQR 5-14), including nine (82%) who were discharged on oral anticoagulation. Anticoagulation had no effect on patency or chronic symptoms (p = 0.931).
The presentation of ATOS is diverse. Preoperative chronic forearm or hand pain and brachial artery occlusion were associated with chronic pain and weakness following thoracic outlet decompression. Delayed thoracic outlet decompression was associated with an increased risk of recurrent thromboembolic events in patients who presented with ALI. An early and accurate diagnosis of ATOS is necessary to reduce morbidity and optimize outcomes.
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