RESUMO
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.
Assuntos
Flebografia , Costelas , Síndrome do Desfiladeiro Torácico , Grau de Desobstrução Vascular , Humanos , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/cirurgia , Síndrome do Desfiladeiro Torácico/fisiopatologia , Feminino , Masculino , Estudos Retrospectivos , Adulto , Costelas/cirurgia , Costelas/diagnóstico por imagem , Adulto Jovem , Resultado do Tratamento , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Fatores de Tempo , Veia Subclávia/diagnóstico por imagem , Veia Subclávia/cirurgia , Veia Axilar/diagnóstico por imagem , Veia Axilar/cirurgia , Cuidados Intraoperatórios , Valor Preditivo dos Testes , Terapia Trombolítica/efeitos adversosAssuntos
Anormalidades Musculoesqueléticas , Costelas , Síndrome do Desfiladeiro Torácico , Descompressão Cirúrgica , Humanos , Anormalidades Musculoesqueléticas/complicações , Costelas/anormalidades , Costelas/diagnóstico por imagem , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: The cervical rib can be a rare finding in asymptomatic subjects. When it produces compression, it affects variably the vasculo-nervous structures of the brachial plexus; the clinical history is progressive. The imaging studies indicate the site of osteo-neuro-vascular conflict and electrophysiological studies indicate the degree of neural involvement. CASE REPORT: We present a patient with an eight-month history of paresis and right dysesthesias, with an image of bilateral cervical ribs with different anatomical characteristics. This case discusses how a variant of the anatomy produces pathology and when it is not related to compression.
ANTECEDENTES: La costilla cervical puede ser un raro hallazgo en sujetos asintomáticos. Cuando produce compresión, afecta variablemente a las estructuras vasculonerviosas del plexo braquial. El cuadro clínico es progresivo. Los estudios de imagen indican el sitio de conflicto osteoneurovascular, y los electrofisiológicos, el grado de afección neural. CASO CLÍNICO: Presentamos un paciente con historia de 8 meses de paresia y disestesias derechas, con imagen de costillas cervicales bilaterales con diferentes características anatómicas. Con este caso se discute cómo una variante de la anatomía produce patología y cuando no está relacionada a compresión.
Assuntos
Plexo Braquial , Costela Cervical , Síndrome do Desfiladeiro Torácico , Costela Cervical/diagnóstico por imagem , Costela Cervical/cirurgia , Humanos , Pressão , Síndrome do Desfiladeiro Torácico/complicações , Síndrome do Desfiladeiro Torácico/diagnóstico por imagemRESUMO
BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.
Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/anormalidades , Descompressão Cirúrgica/efeitos adversos , Traumatismos dos Nervos Periféricos/etiologia , Nervo Frênico/anormalidades , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Humanos , Masculino , Maryland , Traumatismos dos Nervos Periféricos/fisiopatologia , Philadelphia , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Resultado do TratamentoRESUMO
The cervical rib (CR) is a rare skeletal anomaly, which generally articulated with the transverse process of the 7th cervical vertebra, and commonly lead to compression of neurovascular structures in the region of the thoracic outlet. CRs are divided into 2 classes as complete and incomplete forms. A clarifying description of the so-called complete CR form has not been found with sufficient information in the literature. We aimed to present a novel case of an anomalous, supernumerary, extra, or additional rib which arises from the seventh cervical vertebra. We present the case of a 23-year-old female who presented with a mass described as slowgrowing since her childhood in the supraclavicular region. The patient complained of pain, numbness, weakness, and difficulty in lifting her right arm, which increased gradually over in the last 6 months. Physical examination revealed findings of thoracic outlet syndrome (TOS). Radiographic analysis demonstrated a huge cervical rib, which resembles the size of a real thoracic rib. The cervical rib was completely resected through the supraclavicular approach. There is not enough data in theliterature about different morphologic properties of CRs. It is presented with 3-D CT images before and after surgical resection. The final version of the transformation of C7 transverse process to an original Thoracic Rib is shown. As a result, the following question presented, can it be called a Zeroth Rib?.
La costilla cervical (CC) es una anomalía esquelética rara, que generalmente se articula con el proceso transverso de la séptima vértebra cervical y generalmente conduce a la compresión de estructuras neurovasculares en la región de salida torácica. Las CC se dividen en 2 clases, como formas completas e incompletas. No se ha encontrado una descripción aclaratoria de la forma completa de CC, con información insuficiente en la literatura. El objetivo de este trabajo fue presentar un nuevo caso de costilla anómala, supernumeraria, extra o adicional que surge de la séptima vértebra cervical. Exponemos el caso de una mujer de 23 años que presentó una masa descrita como de crecimiento lento desde su infancia en la región supraclavicular. La paciente relató dolor, entumecimiento, debilidad y dificultad para levantar el miembro superior derecho, con un aumento gradual de sus síntomas en los últimos 6 meses. El examen físico reveló hallazgos del síndrome de salida torácica (SST). El análisis radiográfico demostró una costilla cervical de tamaño importante, que se asemejaba al tamaño de una costilla torácica real. La costilla cervical fue resecada completamente a través de un abordaje supraclavicular. No hay suficientes datos en la literatura sobre las diferentes características morfológicas de las CC. Se presentan imágenes tridimensionales de tomogracía computarizada, antes y después de la resección quirúrgica. Se muestra la versión final de la transformación del proceso transverso de C7 a una costilla torácica original. Como resultado, se plantea la siguiente pregunta, ¿se puede denominar a esta costilla como "costilla cero"?.
Assuntos
Humanos , Feminino , Adulto Jovem , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Costela Cervical/cirurgia , Costela Cervical/diagnóstico por imagem , Costelas/anormalidadesRESUMO
A compressão da artéria subclávia no desfiladeiro torácico é um fenômeno amplamente conhecido. Anormalidades ósseas, como a pseudoartrose da clavícula, podem raramente causar compressão arterial a esse nível. A pseudoartrose pode desenvolver-se em decorrência de um trauma, que é a forma mais comum, ou ser congênita. Os autores descrevem o caso de uma paciente de 44 anos com quadro de isquemia crítica de membro superior direito. Apresentava história de fratura não tratada de clavícula direita aos 9 meses de idade que evoluiu com pseudoartrose e compressão extrínseca com oclusão da artéria subclávia. O segmento da clavicula acometido pela pseudoartrose foi ressecado e realizada uma tromboembolectomia tardia das artérias subclávia, braquial e distais, com boa evolução.
Compression of the subclavian artery in the thoracic outlet is a well-known phenomenon. In rare cases, bone abnormalities, such as pseudarthrosis of the clavicle, can cause arterial compression at this level. Pseudarthrosis may develop as a result of trauma, which is the more common form, or it may be congenital. Here, the authors describe the case of a 44-year-old patient with critical ischemia of the right upper limb. She had a history of untreated right clavicle fracture at 9 months of age which had progressed to pseudarthrosis and extrinsic compression of the subclavian artery causing occlusion. The segment of the clavicle involved was resected and late thromboembolectomy of the subclavian, brachial, distal arteries was performed, with good results.
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Clavícula/anormalidades , Pseudoartrose/patologia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/reabilitação , Extremidade Superior/patologia , Artéria Subclávia/anatomia & histologia , Fatores de Tempo , Varfarina/administração & dosagemRESUMO
BACKGROUND: Transaxillary approach to first rib resection and scalenectomy (TAFRRS) is a well-established technique for treatment of thoracic outlet syndrome (TOS). Although anatomic features encountered during TAFRRS are in general constant, vascular anomalies may be encountered but have not been described to date. Herein we describe vascular abnormalities encountered during TAFRRS. METHODS: We performed a retrospective review of a prospective practice database of 224 operations for TOS performed in 172 patients from March 2000 to March 2014. We excluded 10 patients with missing operative reports, 3 reoperations on the same patient, and 8 non-transaxillary resections. We recorded vascular anomalies identified in operative reports and reviewed computed tomography imaging to delineate the nature of these abnormalities. RESULTS: The overall incidence of vascular anomalies was 11% (22 of 203 TAFRRS). Most patients with anomalies had venous TOS (vTOS) (9 patients, 41%), followed by 7 (32%) with neurogenic TOS (nTOS). The remainder of the patients had arterial TOS (aTOS) (6 patients, 27%). Seven patients (32%) had an abnormal subclavian artery (SCA) with 5 (23%) having an abnormal arterial course in the anterior scalene muscle (ASM); 6 patients (27%) had an abnormal internal mammary artery (IMA) originating from distal SCA; 4 (18%) had abnormalities in the supreme thoracic artery (bifurcation or duplication); 2 (9%) had an abnormal branch from the SCA with anomalous location in the operative field; and 3 (14%) had an abnormal large venous branch penetrating the ASM. In the 19 patients with arterial anomalies, 8 (42%) were recognized as arterial branches penetrating the ASM, and 11 (58%) were noticed as they had anomalous arterial locations within the operative field. Most arterial anomalies were seen in vTOS (9, 45%), followed by nTOS (7, 35%). No intraoperative vascular complications occurred. Perioperative complications included 1 occurrence of postoperative transfusion for bleeding following axillary drain discontinuation and 2 Horner's syndromes. One aberrant IMA was electively ligated to allow complete thoracic outlet decompression. CONCLUSIONS: Arterial anomalies during TAFRRS are encountered in 11% of operations, and may present with vessel locations in unusual areas within the operative field, or as abnormal vessels penetrating the ASM, thus making scalenectomy precarious. Careful attention must be paid to possible abnormal locations of vessels in the thoracic outlet to avoid bleeding complications.
Assuntos
Achados Incidentais , Osteotomia , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/cirurgia , Malformações Vasculares/epidemiologia , Adulto , Perda Sanguínea Cirúrgica , Colorado/epidemiologia , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Osteotomia/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Estudos Retrospectivos , Costelas/diagnóstico por imagem , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/epidemiologia , Tomografia Computadorizada por Raios X , Malformações Vasculares/diagnóstico por imagemRESUMO
Correct localization of perineural compressions and adhesions is essential for effective pain relief in the use of local anesthetics, anti-inflammatory drugs, and neurolytic agents for lysis of adhesion by hydraulic distention, blunt dissection, or formal surgery. This article presents a method of entering and navigating the neurovascular sheath of the brachial plexus, the perinueral space of its terminal branches, and the carotid sheath using a catheter/guidewire system for imaging, testing motor function, administering pharmaceuticals, and lysing adhesions.