Successful Return to Active Duty after FirstRib Resection for Thoracic Outlet Syndrome
Kimberly A. Thompson, Michael J. Paisley, Meghann E. Nelles, and Kevin M. Casey, San
Diego and Santa Barbara, California
Background: The optimal surgical approach and treatment algorithm for thoracic outlet syndrome (TOS) remain controversial. We sought to examine the outcomes of patients treated at
a military medical treatment facility (MTF) for TOS.
Methods: A retrospective review was performed on all patients who had a first rib resection
(FRR) for TOS over a 9-year period at a single MTF. Patient demographics, perioperative details,
and patient outcomes were examined. Active duty (AD) status and return to AD were
reviewed.
Results: From 2008 to 2016, 33 FRRs were performed in 32 patients. Of these, 30 patients
were on AD with a mean age of 27 years (range, 19e44). The 29 male and 4 female patients
were treated for symptoms of venous (23), neurogenic (6), or arterial (4) TOS. The mean
time from onset of symptoms was 11 months (range, 1 to 120). The FRR was performed via
a transaxillary (13), supraclavicular (12), or paraclavicular (8) approach. Of 21 AD patients
with venous TOS, 16 (76%) underwent preoperative thrombolysis. A postoperative venogram
or ultrasound was performed in 20 patients, documenting vein patency in 18 (90%). Nine patients
underwent subsequent venoplasty or stent placement. Most patients (15) were placed
on anticoagulation for 1e6 months. Two AD patients had perioperative complications including
a lymph leak and brachial plexus palsy. Twenty-four (89%) patients returned to AD status. One
recruit never returned to AD after successful FRR, and two other patients did not return for medical reasons unrelated to the FRR.
Conclusions: Despite a variety of surgical approaches and often delayed presentation, we
identified a high percentage of postoperative vein patency and return to AD status in our population. The debate over surgical approach remains; however, a multimodal approach individualized to the patient’s presentation and meticulous surgical technique led to successful outcomes in our healthy military population.
INTRODUCTION
Thoracic outlet syndrome (TOS) is a complex medical condition. Rather than one entity, it is instead three different processes each causing external compression on either the subclavian artery, subclavian vein, and/or the brachial plexus. Neurogenic (nTOS) is the most common (80%), followed by venous (vTOS; 20%) and arterial (aTOS; <1%). While surgery is frequently not the initial treatment for nTOS, first rib resection (FRR) is the standard therapy for arterial and venous TOS.
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