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SVS Comprehensive Vascular Review CourseSeptember 9-10, 2011
Intercontinental Chicago OHare
Subclavian/Axillary lesions
and Thoracic Outlet SyndromeMitchell W. Cox, MD
Disclosure
I have no relationships to disclose.
There is mention of off-label use of medical
devices in my presentation.
Possible Causes of
Subclavian/Axillary Stenosis
Atherosclerosis
Radiation Arteritis
Takayasus
Giant Cell
Trauma
Thoracic Outlet
Presentation
Flow limitation vs. embolic
Innominate
TIA/CVA
Arm Weakness
Subclavian
Steal with vertebrobasilar symptoms
Arm weakness
Hand emboli
Cardiac symptoms S/P LIMA-LAD CABG
Axil lary
Frequent arm symptoms
Possible embolization
62yo female
Heavy smoker Referred for
mild arm
weakness
40mm BP
differential
25yo female with
arm/hand pain
and weakness Pulseless left
arm on PE
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67yo female S/P mastectomy/radiation for
CA
Chronic lymphedema New gangrene of the thumb
Diagnostic Evaluation
Physical exam
Pulses Bruits
Differential Arm pressures
Contrast imaging
CTA
Angiogram
Treatment
Open Surgical
Extra-anatomic
Direct aorto-
innominate/subclavian
Endovascular
Angioplasty and stent
Direct Aorto-subclavian/innominate
Reconstruction
Advantages
Most durable
Primary patency >95% at 5 years
sa van ages
Procedural morbidity
Current status
Rarely used in practice
May be best suited for innominate
lesions/diffuse disease
Reasonable in patient requiring CABG
Direct Bypass OptionsExtra-anatomic
options
Configurations
Ax-Ax
Carotid-carotid
Carotid-subclavian bypassl i i i i Subclavian-carotid transposition
Advantages
Very low procedural Morbidity
Disadvantages
May have compromised inflow in diffuse
disease
Patency may be less Ax-Ax patency as low as 50% at 5yr.
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Angioplasty and Stent
Ideal for proximal subclavian lesions
No encroachment on vertebral or LIMA-LAD No involvement of the thoracic outlet
Balloon-expandable stents
Slight overhang into aorta for oroficial lesions
Marginal stent
candidate
Partially
encroaching
Extending
into thoracic
outlet
58yo male with
right arm
weakness
Vague
dizziness
3v coronary
disease at
cardiac cath
Classic Extra-
Anatomic
67yo female
with ongoing
chest pain
after recent
CABG with
LIMA-LAD Carotid-subclavian
bypass
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CY: 67yo female
Presents complaining of left arm
weakness/pain Reports severe weakness and pain of
9/12/2011 19
, ,
effort
Unable to do usual daily activities
Hx. of CABG, hyperlipidemia
60mm Systolic BP gradient left-to-right
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Preferred option
likely carotid-
brachial bypass
Long-segment
Crosses thoracic
outlet
Non-diseased
carotid
67yo female S/P mastectomy/radiation for
CA
Chronic lymphedema
New gangrene of the thumb
Long-segment axillary/brachial stenting
performed by radiology
Initial improvement with some wound
healing, but occluded at 3mo.
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Thoracic Outlet Syndrome
Distinct resentation from atherosclerotic disease
in virtually every case
Present in the young, active, non-atherosclerotic
population
29yo female with right arm
swelling
Reports sudden onset of severe, painful and
disabling right arm swelling 4 months prior
Presented to student health and was sent home
with ASA and a referral to PT
Painful symptoms resolved and severe swelling
improved, but has persistent mild swelling
Referral to Vascular 4 months later
Pt. is a former competitive swimmer
Physical exam:
Right arm slightly larger than the left
Few prominent venous collaterals about
Strong radial pulse
CXR
Venogram
Arm in adduction Arm in abduction
Anatomy of the Thoracic
Outlet
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Thoracic Outlet Syndrome Thoracic Outlet Syndrome
Thoracic Outlet SyndromeEpidemiology of Thoracic Outlet
Syndrome
develops during the 3rd or 4th decade
classically said to occur in thin, athletic
females and males with pronounced upper
body development (weightlifters)
Female/male ratio as high as 4:1
Types of TOS
95
70
80
90
100
1 3
0
10
20
30
40
50
60
%
Arterial
Venous
Neurogenic
Diagnosis of Thoracic Outlet
SyndromeCXR
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Diagnosis of Thoracic Outlet
SyndromeCXR Bony Anomalies
Diagnosis of Thoracic OutletPhysical exam
EAST Test or "Hands-up" Test
The patient brings their arms up as shown with
elbows slightly behind the head. The patient then
opens and closes their hands slowly for 3 minutes.
A positive test is indicated by pain, heaviness or
profound arm weakness or numbness and tingling
of the hand.
Diagnosis of Thoracic Outlet
Adson or Scal ene Maneuver
The examiner locates the radial pulse. The patient
rotates their head toward the tested arm and lets
the head tilt backwards (extends the neck) while
the examiner extends the arm. A positive test is
Physical exam
indicated by a disappearance of the pulse.
Caveat: Change in pulse amplitude in up to 53% of
normal volunteers
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Arterial TOS
Upper extremity
embolization
Pulsatilesupraclavicular
mass
Sudden onset arm
ischemia
Arterial TOS: Uniformly
straightforward with good resultsArter ial i njuri es in the t hor acic
outlet syndromeJoseph R. Durham, MD, James S. T. Yao, MD, PhD, William H. Pearce, MD ,
Gordon M. Nuber, MD, and Walter J. McCarthy III, MD, Chicago, Ill.
22 patients with arterial TOS and subclavian artery injury
73% with a cervical rib
50% with distal embolization
50 % requiring arterial reconstruction
All underwent thoracic outlet decompression
100% patency at F/U
J Vasc Surg. 1995 Jan;21(1):57-69
Arterial TOS: Axillary variant
Compression of the axillary artery by the humoral head with
repetitive stress in certain athletes (mainly pitchers)
Art eria l in ju ries in t he th oracic
outlet syndromeJoseph R. Durham, MD, James S. T. Yao, MD, PhD, William H. Pearce, MD,
Gordon M. Nuber, MD, and Walter J. McCarthy III, MD, Chicago, Ill.
12 patients with axillary artery involvement
thrombosis (1), aneurysm (2),
symptomatic extrinsic compression only (9).
Five patients treated without a surgical procedure;
three underwent decompression procedures only,
four had direct arterial repair.
All axillary artery reconstructions were patent at last follow-upexamination (mean 31 months).
J Vasc Surg. 1995 Jan;21(1):57-69
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Venous TOS
Upper Extremity Swelling
Differential diagnosis
Lymphedema
Superior vena cava syndrome
Axillo-subclavian vein thrombosis
Pacer wires
lli i lli i
Paget Schroetter syndrome
Axillo-subclavian vein
thrombosis
Effected arm
swellin
Standard approach to Paget-
Schroetter
Venogram in adduction and abduction
If symptoms are chronic and subclavian vein
occluded-no therapy
crossed, begin lysis
Thrombolysis until subclavian vein is clear
First rib resection via axillary or supraclavicular approach
May be immediate or delayed
Venous Thoracic Outlet Syndrome
Pre-thrombolysis
Subclavian vein
thrombosis
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Venous Thoracic Outlet Syndrome
Post thrombolysis
Subclavian vein
Patent w/ stenosis
Approach to venous thoracic outlet:
significant variance
The aggressive
First Rib Resection and Scalenectomy forChronically Occluded Subclavian Veins:
What Does It Really Do?Ricardo de Leon, David C. Chang, Christopher Busse,
Four patients with chronic, symptomatic
subclavian vein occlusion
All re-opened after first rib resection
Average of 7 months to recanalization
Diana Call,
and Julie Ann Freischlag, Baltimore, Maryland
The even more aggressive
Comprehensive surgical management of the
competitive athlete with effort thrombosis of
the subclavian vein (Paget-Schroetter
syndrome)
Spencer J. Melby, MD, Suresh Vedantham, MD, Vamsidhar R.
Narra, MD, George A. Paletta Jr, MD, Lynnette Khoo-Summers,
MSPT, Matt Driskill, MSPT,
and Robert W. Thompson, MD, St Louis and Chesterfield, Mo
32 competitive athletes with effort thrombosis
81% underwent thrombolysis and 100%
underwent first rib excision and operative
venolysis
44% underwent venous reconstruction via patch
angioplasty or saphenous panel grafts
AVFs created in patients with reconstruction
Three patients with post-op thrombosis
All with return to athletics
22 pts treated between June 1996 and June 1999
i i i
Approach to venous thoracic outlet:
The not-so aggressive
Surgical intervention is not required
for all patients with subclavian vein
Thrombosis
W. Anthony Lee, MD, Bradley B. Hill, MD, E. John Harris, Jr, MD,
Charles P. Semba, MD, and Cornelius Olcott IV, MD , Stanford, Calif
9 of 22 patients (41%) did not require surgery,
Recurrent thrombosis developed in only one patient during anticoagulation.
11 of 13 patients (85%) treated with surgery and 8/9 patients (89%) treated without
surgery sustained durable relief of their symptoms and a return to their baseline
level of physical activity.
All patients who underwent surgery maintained their venous patency on follow-up
duplex
Conclusions
Not all patients with primary axillary-subclavian vein thrombosis require surgicalintervention.
No chronic anticoagulationJ Vasc Surg. 2000 Jul;32(1):57-67
i i i l i i i i i -
Combined rib resection and
PTA
Combination treatment of venous thoracic outlet
syndrome: Open surgical decompression and
intraoperative angioplasty
Darren B. Schneider, MD, Paul J. Dimuzio, MD,c Niels D. Martin, MD, Roy L. Gordon, MD,
Mark W. Wilson, MD, Jeanne M. Laberge, MD, Robert K. Kerlan, MD, Charles M. Eichler, MD,and Louis M. Messina, MD, San Francisco, Calif; and Philadelphia, Pa
i i i l i , i i i i -
venogram/PTA
Intraoperative venography enabled identification of residual subclavian vein
stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100%
technical success.
Postoperative duplex scans documented subclavian vein patency in 23
patients (92%).
recurrent thrombosis in 2 patients (8%),
One-year primary and secondary patency rates were 92% and 96%
Schneider DB, et al (UCSF) J Vasc Surg. 2004 Oct;40(4):599-603
Role of subclavian vein stents s/p 1st rib
resection
Long-term results in patients treated with
thrombolysis, thoracic inlet decompression, and
subclavian vein stenting for Paget-Schroetter
syndromePaul B. Kreienberg, MD, Benjamin B. Chang, MD, R. Clement Darling III, MD, Sean P. Roddy, MD,
Philip S. K. Paty, MD, William E. Lloyd, MD, David Cohen, MD, Brian Stainken, MD, and Dhiraj M.Shah, MD, Albany, NY
23 patients with thrombolysis, first rib resection, and immediate venography
14 pts w/ residual vein stenosis (>50%) after PTA underwent sub clavian vein
stenting
All PTA are paten t, wi th a mean fo llo w-up o f 4 years (r ange, 2-6 years).
9 of 14 stents patent, with a mean fol low-up of 3.5 years
ConclusionPatients with short-segment venous strictures after successful lysis and thoracic
outlet decompression may safely be tr eated with subclavian venous stents and can
expect long-term patency
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Conservative criteria for surgical
intervention
Classic Physical exam findings Failed 3-6 month trial of Physical therapy
euro ogy ru es ou o er causes
cervical radiculopathy
Scalene block relieves symptoms
Not on Workmans comp.
Operative Options
First rib resection Scalenectomy
Cervical rib resection
Brachial plexus neurolysis
Recurrent TOS
Supraclavicular approach
Anterior/middle scalene resection if not
previously done
rst r resect on not prev ous y one
Complete neurolysis
Results of Surgery: highly
variableThe Good
Reported In-Hospital Complications
following Rib Resections for Neurogenic
Thoracic Outlet Syndrome
David C Chan AnneO Lidor SusannaL Matsen and JulieA Freischla
National Inpatient sample: 2016 TOS
operations
Average length of stay 2.51 days
.60% rate of brachial plexus injury
1.74% rate of vascular injury
Concludes that TOS surgery is safe
. , . , . , . ,
Baltimore,Maryland
Ann Vasc S urg. 2007 Sep t;21(5)564-70 .
Clinical research study
Surgical intervention for thoracic outlet syndrome
improves patient's quality of life Presented at the 2008
Vascular Annual Meeting, San Diego, Calif, Jun 5-8,
2008.
David C. Chang PhD, MPH, MBA, Lisa A. Rotellini-Coltvet MA, MMS, PA-C, Debraj Mukherjee MD, MPH, Ricardo
De Leon MD and Julie A. Freischlag MD
70 patients operated on for neurogenic or venous TOS
ll l i ili l ll comple e - an isa ili y arm , an , s oul er
surveys pre and post-op
Significant improvement in scores at 24 months post-op
JVS Volume 49, Issue 3, March 2009, Pages
630-637
Results of SurgeryThe bad
i i i
Long-term functional outcome of neurogenic
thoracic outlet syndrome in surgically and
conservatively treated patientsGregory J. Landry, MD, Gregory L. Moneta, MD, Lloyd M. Taylor, Jr, MD, James M. Edwards,
MD,
and John M. Porter, MD, Portland, Ore
79 patients with neurogenic TOS
Divided into operative and non-operative groups
34% of operative groups with significant symptomatic
improvement32% of non-operative group with improvement
60% of operative group returned to work, 78% of non-operative
group
Concluded first rib resection does not improve functional
outcome
J Vasc Surg. 2001 Feb;33(2):312-7
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TOS and Workmans Comp: The
Really Bad
Outcome of surgery for thoracic outlet
syndrome in Washington state
workers compensationGary M. Franklin, MD; Deborah Fulton-Kehoe, MPH; Cynthia Bradley, MS, MPH;
and Terri Smith-Weller, MN
158 Pts. Operated for TOS
60% still disabled at one year
70% with significant limitations
Significantly less lost work days inconservatively managed patients
30% with an acute complication
17% with a new neurologic complaintafter surgery
First Rib Resection Operative
Approaches Transaxillary
Cosmetically appealing
Avoids venous collaterals
More difficult to do neurolysis or arterial reconstruction
Better exposure of cervical rib and brachial plexus
Familiar dissection
Difficult to do arterial repair
Difficult to fully release the most medial compression of the vein
Paraclavicular Maximum exposure for arterial reconstruction/rib resection
Cosmetically less appealing
Supraclavicular Approach Supraclavicular Approach
The platysma is opened and the
external jugular vein isolated and
divided
The clavicular head of the sternocleidomastoid muscle is
divided and the underlying scalene fat pad dissected from
lateral to medial
Supraclavicular approach Supraclavicular Approach
The anterior scalene muscle was exposed and
the medial cord of the brachial plexus was
encircled with a vessel loop and gently retracted
laterally.
The subclavian artery was encircled with a vessel loop
and retracted medially. The anterior scalene muscle was
carefully divided, exposing the first rib.
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Supraclavicular Approach
The first rib is cleared of intercostal muscular
attachments and resected with small bites of a
double action rongeur.
The cut end of the first rib is visible between the
subclavianartery and brachial plexus
Transaxillary Approach
Anatomy of the Thoracic Outlet Anatomy of the Thoracic Outlet
Thoracic Outlet Syndrome Summary Subclavian/Axillary Atherosclerosis
Rarely Symptomatic
May be due to flow limitation or atheroembolic
Usually treated with angioplasty/stent or extranatomic bypass
Occasionally direct aortic-based reconstruction
Thoracic Outlet Presentation
i i i i l i ree is inc presen a ionsar erial, venous, neurogenic
Arterial due to bony abnormalityMay be embolic or flow-limiting
Venous presenting as effort thrombosis
Neurogenic with pain paresthesias in unpredictable upper ext. neck
distribution
Thoracic Outlet Treatment
Arterial: first/cervical rib resection and often arterial interposition
graft
Venous: thrombolysis, first rib resction, venogram with angioplasty
Neurogenic: First rib resection with scalenectomy