RESUMEN
Thoracic outlet syndrome is a challenging clinical condition in terms of diagnosis, treatment, and health-related quality of life assessment. In this review, the authors provide a description of the clinical approach, surgical management, and longitudinal follow-up for patients with neurogenic, venous, and arterial thoracic outlet syndrome. The review represents the experiences of a high-volume, dedicated thoracic outlet syndrome program, where patients are treated in a multidisciplinary team and operative decompression occurs through primarily a supraclavicular approach. Data supporting the safety and efficacy of this approach are provided, as are clinical care considerations for surgeons treating patients with thoracic outlet syndrome.
Asunto(s)
Descompresión Quirúrgica , Síndrome del Desfiladero Torácico , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico , Humanos , Descompresión Quirúrgica/métodos , Resultado del Tratamiento , Clavícula , Calidad de VidaRESUMEN
Neurogenic thoracic outlet syndrome (nTOS) is caused by brachial plexus compression in the thoracic outlet. It accounts for 85%-95% of thoracic outlet syndrome (TOS) cases, which may also be caused by compression of the subclavian artery and vein. Compression occurs in the interscalene triangle, costoclavicular space or subpectoralis minor space, with congenital anomalies and repetitive overhead activities as contributing factors. Diagnosis is challenging due to overlapping symptoms with other conditions. Patients commonly report pain, numbness, tingling and weakness in the neck, shoulder and arm, exacerbated by arm elevation. Symptoms related to nTOS may manifest in the distribution of the upper (C5-C6), middle (C7) and lower plexus (C8-T1). Although widely used, provocative tests have varying degrees of sensitivity and specificity and may have high false-positive rates, complicating the diagnosis. Patterns on electrodiagnostic studies provide key diagnostic clues, such as reduced sensory response in the medial antebrachial cutaneous nerve and low compound motor action potential in the median nerve. Imaging techniques like magnetic resonance imaging (MRI), alongside procedures like diagnostic and therapeutic anterior scalene blocks, assist in identifying anatomical abnormalities and predicting surgical outcomes. Management of nTOS involves lifestyle changes, physical therapy, medication and botulinum toxin injections for symptomatic relief. Surgical options may include supraclavicular, transaxillary and infraclavicular approaches, each offering specific benefits based on patient anatomy and surgeon expertise. Minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery, enhance exposure and dexterity, leading to better outcomes. Future research should focus on developing precise diagnostic tools, understanding nTOS pathophysiology, standardising diagnostic criteria and surgical approaches, comparing long-term treatment outcomes and exploring preventive measures to improve patient care and quality of life. Level of Evidence: Level V (Therapeutic).
Asunto(s)
Síndrome del Desfiladero Torácico , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/terapia , Síndrome del Desfiladero Torácico/cirugía , Humanos , Descompresión Quirúrgica/métodos , Electrodiagnóstico/métodosRESUMEN
INTRODUCTION: Thoracic outlet syndrome (TOS) typically considered a condition of the adult population; it is often disregarded in children and adolescents due to its limited recognition within the pediatrics. The current study aims to systematically review and provide insights into TOS among pediatric patients. METHODS: PubMed, Scopus, Web of Science, and Google Scholar databases were thoroughly searched for English language studies published until March 15th, 2024. The study included those articles focusing on pediatric or adolescent individuals diagnosed with TOS. Data collected from studies encompassed date of publication, number of participants or reported cases, age (years), gender of participants, type of TOS, affected side, type of treatment, surgical approach, bony abnormality, duration of symptoms (months), outcome, and follow-up time duration (months). RESULTS: The current study comprised 33 articles, 21 of which were case reports, 10 of which were case series, and the remaining were cohort studies. In this study, 356 patients were included. Females constituted 234 (65.73%) of the patient population. Among TOS types, neurogenic TOS was found among 201 (56.5%) patients. Sporting-related activity or physical activity was present in 193 (54%) patients, followed by a history of trauma in 27 (7%) patients. CONCLUSIONS: Pediatric patients exhibited a higher percentage of vascular TOS than their adult counterparts, with the supraclavicular approach emerging as the preferred treatment method. Sports-related activities were identified as the primary risk factor associated with pediatric TOS.
Asunto(s)
Síndrome del Desfiladero Torácico , Humanos , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico , Adolescente , Niño , Masculino , FemeninoRESUMEN
OBJECTIVE: Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS. METHODS: We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ2 test to compare baseline characteristics and postoperative outcomes. RESULTS: Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84). CONCLUSIONS: TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency.
Asunto(s)
Descompresión Quirúrgica , Osteotomía , Costillas , Síndrome del Desfiladero Torácico , Grado de Desobstrucción Vascular , Humanos , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/fisiopatología , Femenino , Masculino , Estudios Retrospectivos , Costillas/cirugía , Costillas/diagnóstico por imagen , Adulto , Resultado del Tratamiento , Descompresión Quirúrgica/efectos adversos , Descompresión Quirúrgica/métodos , Osteotomía/efectos adversos , Factores de Tiempo , Adulto Joven , Persona de Mediana Edad , Vena Axilar/cirugía , Vena Axilar/diagnóstico por imagen , Vena Axilar/fisiopatología , Vena Subclavia/diagnóstico por imagen , Vena Subclavia/cirugía , Vena Subclavia/fisiopatologíaRESUMEN
BACKGROUND: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). METHODS: We performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS: Fifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. CONCLUSIONS: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.
Asunto(s)
Flebografía , Costillas , Síndrome del Desfiladero Torácico , Grado de Desobstrucción Vascular , Humanos , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/fisiopatología , Femenino , Masculino , Estudios Retrospectivos , Adulto , Costillas/cirugía , Costillas/diagnóstico por imagen , Adulto Joven , Resultado del Tratamiento , Persona de Mediana Edad , Osteotomía/efectos adversos , Factores de Tiempo , Vena Subclavia/diagnóstico por imagen , Vena Subclavia/cirugía , Vena Axilar/diagnóstico por imagen , Vena Axilar/cirugía , Cuidados Intraoperatorios , Valor Predictivo de las Pruebas , Terapia Trombolítica/efectos adversosRESUMEN
BACKGROUND: Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. PURPOSE/HYPOTHESIS: The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. RESULTS: Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. CONCLUSION: The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.
Asunto(s)
Rendimiento Atlético , Béisbol , Volver al Deporte , Síndrome del Desfiladero Torácico , Humanos , Béisbol/lesiones , Síndrome del Desfiladero Torácico/cirugía , Volver al Deporte/estadística & datos numéricos , Adulto , Masculino , Adulto Joven , Estudios de Casos y Controles , Estudios Retrospectivos , Estudios de CohortesRESUMEN
Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic).
Asunto(s)
Escápula , Síndrome del Desfiladero Torácico , Humanos , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/epidemiología , Síndrome del Desfiladero Torácico/cirugía , Masculino , Femenino , Adulto , Persona de Mediana Edad , Estudios Retrospectivos , Adulto Joven , Estudios Prospectivos , Examen FísicoRESUMEN
The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use-related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.
Asunto(s)
Atletas , Síndrome del Desfiladero Torácico , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/terapia , Síndrome del Desfiladero Torácico/fisiopatología , Síndrome del Desfiladero Torácico/etiología , Síndrome del Desfiladero Torácico/cirugía , Humanos , Resultado del Tratamiento , Factores de Riesgo , Recuperación de la Función , Traumatismos en Atletas/terapia , Traumatismos en Atletas/diagnóstico , Traumatismos en Atletas/fisiopatología , Osteotomía/efectos adversos , Volver al Deporte , Valor Predictivo de las Pruebas , Descompresión Quirúrgica/efectos adversos , Modalidades de FisioterapiaRESUMEN
Compression of the neurovascular structures at the level of the scalene triangle and pectoralis minor space is rare, but increasing awareness and understanding is allowing for the treatment of more individuals than in the past. We outlined the recognition, preoperative evaluation, and treatment of patients with neurogenic thoracic outlet syndrome. Recent work has illustrated the role of imaging and centrality of the physical examination on the diagnosis. However, a fuller understanding of the spatial biomechanics of the shoulder, scalene triangle, and pectoralis minor musculotendinous complex has shown that, although physical therapy is a mainstay of treatment, a poor response to physical therapy with a sound diagnosis should not preclude decompression. Modes of failure of surgical decompression stress the importance of full resection of the anterior scalene muscle and all posterior rib impinging elements to minimize the risk of recurrence of symptoms. Neurogenic thoracic outlet syndrome is a rare but critical cause of disability of the upper extremity. Modern understanding of the pathophysiology and evaluation have led to a sounder diagnosis. Although physical therapy is a mainstay, surgical decompression remains the gold standard to preserve and recover function of the upper extremity. Understanding these principles will be central to further developments in the treatment of this patient population.
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Descompresión Quirúrgica , Síndrome del Desfiladero Torácico , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/fisiopatología , Síndrome del Desfiladero Torácico/terapia , Síndrome del Desfiladero Torácico/cirugía , Humanos , Resultado del Tratamiento , Valor Predictivo de las Pruebas , Modalidades de Fisioterapia , Recuperación de la Función , Factores de Riesgo , Examen Físico , Fenómenos Biomecánicos , Diagnóstico por Imagen/métodosRESUMEN
Clavicle fractures are a common injury in adults. Most patients are treated non-operatively. In this case report, a 53-year-old professional violinist had a midt shaft clavicula fracture and was treated non-operatively. The fracture healed, but the patient developed thoracic outlet syndrome (TOS) and a venous thrombosis when playing violin. Surgery with restoration of the normal anatomy alleviated the symptoms and six months later she was symptom free and playing violin again. TOS is a rare complication to clavicle fractures and the treating doctors should be aware of the diagnosis.
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Clavícula , Fracturas Mal Unidas , Síndrome del Desfiladero Torácico , Humanos , Clavícula/lesiones , Síndrome del Desfiladero Torácico/etiología , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/diagnóstico , Femenino , Persona de Mediana Edad , Fracturas Mal Unidas/cirugía , Fracturas Mal Unidas/diagnóstico por imagen , Fracturas Mal Unidas/complicaciones , Fracturas Óseas/complicaciones , Fracturas Óseas/cirugía , Fracturas Óseas/diagnóstico por imagen , MúsicaRESUMEN
Patients with threatened arteriovenous access are often found to have central venous stenoses at the ipsilateral costoclavicular junction, which may be resistant to endovascular intervention. Stenoses in this location may not resolve unless surgical decompression of thoracic outlet is performed to relieve the extrinsic compression on the subclavian vein. The authors reviewed the management of dialysis patients with central venous lesions at the thoracic outlet, as well as the role of surgical decompression with first-rib resection or claviculectomy for salvage of threatened, ipsilateral dialysis access.
Asunto(s)
Derivación Arteriovenosa Quirúrgica , Descompresión Quirúrgica , Diálisis Renal , Síndrome del Desfiladero Torácico , Humanos , Clavícula/diagnóstico por imagen , Clavícula/cirugía , Osteotomía/efectos adversos , Costillas/cirugía , Factores de Riesgo , Vena Subclavia/diagnóstico por imagen , Vena Subclavia/cirugía , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/etiología , Síndrome del Desfiladero Torácico/cirugía , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Surgical decompression of the thoracic outlet, along with treatment of the involved nerve or vessel, is the accepted treatment modality when indicated. Although neurogenic thoracic outlet syndrome (TOS) is often operated via the axillary approach and venous TOS via the paraclavicular approach, arterial TOS is almost always operated via the supraclavicular approach. The supraclavicular approach provides excellent access to the artery, brachial plexus, phrenic nerve, and the cervical and/or first ribs, along with any bony or fibrous or muscular abnormality that may be causing compression of the neurovascular structures. Even for neurogenic TOS, for which the axillary approach offers good cosmesis, the supraclavicular approach helps with adequate decompression while preserving the first rib. This approach may also be sufficient for thin patients with venous TOS. For arterial TOS, a supraclavicular incision usually suffices for excision of bony abnormality and repair of the subclavian artery.
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Descompresión Quirúrgica , Síndrome del Desfiladero Torácico , Humanos , Descompresión Quirúrgica/métodos , Arteria Subclavia/cirugía , Arteria Subclavia/diagnóstico por imagen , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/fisiopatología , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Resultado del TratamientoRESUMEN
Thoracic outlet syndrome (TOS) is observed more frequently in women, although the exact causes of this sex disparity remain unclear. By investigating the three types of TOS-arterial, neurogenic, and venous-regarding symptoms, diagnosis, and treatment, this article aims to shed light on the current understanding of TOS, focusing on its variations in women.
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Síndrome del Desfiladero Torácico , Humanos , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/terapia , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/fisiopatología , Femenino , Factores de Riesgo , Factores Sexuales , Disparidades en el Estado de Salud , Resultado del Tratamiento , MasculinoRESUMEN
Arterial thoracic outlet syndrome (TOS) is a condition in which anatomic abnormalities in the thoracic outlet cause compression of the subclavian or, less commonly, axillary artery. Patients are usually younger and typically have an anatomic abnormality causing the compression. The condition usually goes undiagnosed until patients present with signs of acute or chronic hand or arm ischemia. Workup of this condition includes a thorough history and physical examination; chest x-ray to identify potential anatomic abnormalities; and arterial imaging, such as computed tomographic angiography or duplex to identify arterial abnormalities. Patients will usually require operative intervention, given their symptomatic presentation. Intervention should always include decompression of the thoracic outlet with at least a first-rib resection and any other structures causing external compression. If the artery is identified to have intimal damage, mural thrombus, or is aneurysmal, then arterial reconstruction is warranted. Stenting should be avoided due to external compression. In patients with symptoms of embolization, a combination of embolectomy, lytic catheter placement, and/or therapeutic anticoagulation should be done. Typically, patients have excellent outcomes, with resolution of symptoms and high patency of the bypass graft, although patients with distal embolization may require finger amputation.
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Síndrome del Desfiladero Torácico , Humanos , Descompresión Quirúrgica , Procedimientos Endovasculares , Valor Predictivo de las Pruebas , Factores de Riesgo , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/fisiopatología , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/terapia , Síndrome del Desfiladero Torácico/etiología , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Thoracic outlet syndrome (TOS) is a group of conditions thought to be caused by the compression of neurovascular structures going to the upper extremity. TOS is a difficult disease to diagnose, and surgical treatment remains challenging. Many different surgical techniques for the treatment of TOS have been described in the literature and many reasonable to good outcomes have been reported, which makes it hard for surgeons to determine which techniques should be used. Our aim was to describe the rationale, techniques, and outcomes associated with the surgical treatment of TOS. Most patients in our center are treated primarily through a trans-axillary approach. We will elaborate on the technical details of performing trans-axillary thoracic outlet decompression. The essential steps during surgery are illustrated with videos. We focused on the idea behind performing a trans-axillary thoracic outlet decompression in primary cases. Institutional data on the outcomes of this surgical approach are described briefly.
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Descompresión Quirúrgica , Síndrome del Desfiladero Torácico , Humanos , Descompresión Quirúrgica/métodos , Factores de Riesgo , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/diagnóstico , Síndrome del Desfiladero Torácico/fisiopatología , Resultado del TratamientoRESUMEN
Multiple surgical approaches have been used in the management of thoracic outlet syndrome. These approaches have traditionally been "open" approaches and have been associated with the inherent morbidities of an open approach, including a risk of injury to the neurovascular structures due to traction and trauma while resecting the first rib. In addition, there has been concern that recurrence of symptoms may be related to incomplete resection of the rib with conventional open techniques. With the advent of minimally invasive thoracic surgery, surgeons began to explore first-rib resection via a thoracoscopic approach. Unfortunately, the existing video-assisted thoracic surgery technology and equipment was not well suited to working in the apex of the chest. With the introduction and subsequent progress in robotic surgery and instrumentation, this dissection can be performed with all the advantages of robotics, but also with minimal traction and trauma to the neurovascular structures, and incorporates almost complete resection of the rib with minimal residual stump. Robotics has developed as a reliable, safe, and less invasive approach to first-rib resection, yielding excellent results while limiting the morbidity of the procedure.
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Descompresión Quirúrgica , Costillas , Procedimientos Quirúrgicos Robotizados , Síndrome del Desfiladero Torácico , Cirugía Torácica Asistida por Video , Humanos , Descompresión Quirúrgica/métodos , Osteotomía , Costillas/cirugía , Síndrome del Desfiladero Torácico/cirugía , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/fisiopatología , Resultado del TratamientoRESUMEN
Venous thoracic outlet syndrome (vTOS) is an esoteric condition that presents in young, healthy adults. Treatment includes catheter-directed thrombolysis, followed by first-rib resection for decompression of the thoracic outlet. Various techniques for first-rib resection have been described with successful outcomes. The infraclavicular approach is well-suited to treat the most medial structures that are anatomically relevant for vTOS. A narrative review was conducted to specifically examine the literature on infraclavicular exposure for vTOS. The technique for this operation is described, as well as the advantages and disadvantages of this approach. The infraclavicular approach is a reasonable choice for definitive treatment of uncomplicated vTOS.