Thoracic outlet syndrome (TOS) is a group of conditions that involve compression of the nerves or blood vessels that pass through the base of the neck. These conditions come in multiple forms, including venous TOS (VTOS), which impacts major veins in the arm and can result in axillary-subclavian vein (AxSCV) thrombosis.
Treatment for AxSCV thrombosis and VTOS often involves first rib resection, which can be accomplished in various ways. Each treatment protocol has its own advantages and disadvantages. The Washington University Center for Thoracic Outlet Syndrome at Barnes-Jewish Hospital is dedicated to treating and researching this condition. A research team from the Center recently published their findings to assess the clinical presentation, operative findings and long-term results of paraclavicular surgical treatment procedures for VTOS-induced AxSCV thrombosis.
Research Background and Questions
The thoracic outlet is a space located in the lower part of the neck through which a collection of major nerves and blood vessels pass, just above and behind the clavicle. It extends underneath the clavicle to the area just in front of the shoulder. TOS can lead to disabling pain in the neck and shoulder, as well as pain, numbness, tingling and weakness in the hands and fingers.
In venous TOS, one of three principle types of TOS, the condition is caused by compression of the axillary and subclavian veins, the main veins serving the arm. Patients with venous TOS may have the abrupt development of vascular symptoms requiring urgent evaluation and treatment. This type of TOS represents about 10-15% of patients with the condition.
Washington University investigators have recently published a study on the treatment of venous TOS to appear in the March 2023 issue of the Journal of Vascular Surgery, based on research conducted by the vascular surgery team, including director of the Center for Thoracic Outlet Syndrome, Robert Thompson, MD. Thompson is nationally recognized for his treatment of professional and other athletes as well as those who acquire TOS through other activities. Vascular fellow Esmaeel Reza Dadashzadeh, MD, MS, is first author on the publication.
The research team conducted the study, titled “Venographic Classification and Long-Term Surgical Treatment Outcomes for Axillary-Subclavian Vein Thrombosis Due to Venous Thoracic Outlet Syndrome (Paget-Schroetter Syndrome),” on data collected from 2016 through 2022. The project sought to assess clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome.
Methods and Results
A retrospective single-center review was conducted for 266 patients that underwent primary surgical treatment for VTOS between 2016 and 2022. The study population was derived from patients referred to the Washington University Center for Thoracic Outlet Syndrome at Barnes-Jewish Hospital in St. Louis for evaluation and surgical treatment of AxSCV thrombosis and VTOS.
Clinical outcomes were compared between patients in four treatment groups based on intraoperative venography and the method of surgical treatment. All patients underwent standardized paraclavicular thoracic outlet decompression, including complete anterior and middle scalenectomy, mobilization of the brachial plexus nerve roots, subclavius muscle resection, and complete first rib resection. Some patients had removal of scar tissue from around the AxSCV alone, while others underwent AxSCV reconstruction with patch angioplasty of bypass grafting.
The team concluded that paraclavicular decompression, external venolysis and selective AxSCV reconstruction based on intraoperative venography can provide successful and durable treatment for more than 90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt utilization of CDT and even more effective surgical treatment.
Conclusions
“This is the largest detailed study of this condition to be published to date and shows excellent clinical outcomes with long-term follow-up using our relatively unique approach to this problem,” says Thompson. “It has important implications for the initial management of patients with upper extremity venous thrombosis, showing optimal outcomes with early venography and intervention with catheter-directed thrombolysis, followed by definitive surgical treatment.”
First author Dadashzadeh presented the project at the annual meeting of the Midwestern Vascular Surgical Society this September. At this event, Dadashzadeh was the recipient of the John Pheifer award for best venous paper.
Continuing the Legacy with the Center for Thoracic Outlet Syndrome
This research builds off a prestigious program of diagnosis, treatment and patient care for those experiencing TOS and related conditions. In building a nationally recognized referral center for patients with TOS at Washington University, Thompson has developed a highly knowledgeable staff and an effective multidisciplinary team. Associated physicians include experts in physical therapy and rehabilitation, anesthesia and pain management, diagnostic and interventional radiology, neurology and neurosurgery, orthopedic surgery, hand surgery, sports medicine, occupational and environmental health, and a number of other specialties.
Thompson and his team currently evaluate more than 300-400 patients with all forms of TOS annually and perform approximately 250 surgical procedures for these conditions each year, representing an unusually large clinical experience for this group of rare disorders.
For more information, please visit the Washington University Center for Thoracic Outlet Syndrome at Barnes-Jewish Hospital website.
Physicians responsible for this study include
Esmaeel Reza Dadashzadeh, MD, MS
Karen M. Henderson, RN
Danita M. Goestenkors, RMA
Study citation: Esmaeel Reza Dadashzadeh, J. Westley Ohman, Pavan K. Kavali, Karen M. Henderson, Danita M. Goestenkors, Robert W. Thompson. “Venographic Classification and Treatment Outcomes for Axillary-Subclavian Vein Thrombosis Due to Venous Thoracic Outlet Syndrome.” Journal of Vascular Surgery, Nov. 26, 2022.