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SVS Comprehensive Vascular Review Course September 9-10, 2011 Intercontinental Chicago OHare

Disclosure
I have no relationships to disclose.

Subclavian/Axillary lesions and Thoracic Outlet Syndrome

Mitchell W. Cox, MD

There is mention of off-label use of medical devices in my presentation.

Possible Causes of Subclavian/Axillary Stenosis

Atherosclerosis Radiation Arteritis Vasculitis
Takayasus Giant Cell

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

Trauma Thoracic Outlet

Axillary
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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Diagnostic Evaluation
67yo female S/P mastectomy/radiation for CA Chronic lymphedema New gangrene of the thumb

Physical exam
Pulses Bruits Distal ulceration/tissue loss

Differential Arm pressures Contrast imaging

CTA Angiogram

Treatment
Open Surgical
Extra-anatomic Direct aortoaorto innominate/subclavian

Direct Aorto-subclavian/innominate Reconstruction

Advantages
Most durable Primary patency >95% at 5 years

Disadvantages Di d t
Procedural morbidity

Endovascular
Angioplasty and stent

Current status
Rarely used in practice May be best suited for innominate lesions/diffuse disease Reasonable in patient requiring CABG

Direct Bypass Options

Extra-anatomic options
Configurations Ax-Ax Carotid-carotid Carotid-subclavian bypass Subclavian-carotid S b l i tid t transposition iti 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 p stents Balloon-expandable Slight overhang into aorta for oroficial lesions Marginal stent candidate Partially encroaching on vertebral Extending into thoracic outlet

58yo male with right arm weakness Vague dizziness 3v coronary disease at cardiac cath

Classic ExtraAnatomic

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 shoulder forearm, shoulder, forearm hand with very minimal 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 carotidbrachial bypass

Long-segment Crosses thoracic outlet Non-diseased carotid

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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

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

Distinct p presentation from atherosclerotic disease in virtually every case Present in the young, active, non-atherosclerotic population

Physical exam:
Right arm slightly larger than the left Few prominent venous collaterals about the shoulder Strong radial pulse

CXR

Venogram

Anatomy of the Thoracic Outlet

Arm in adduction

Arm in abduction

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Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Epidemiology 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
100 90 80 70 60 50 40 30 20 10 0

Diagnosis of Thoracic Outlet Syndrome CXR

95 Arterial Venous Neurogenic 3 %

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Diagnosis of Thoracic Outlet Syndrome CXR

Bony Anomalies

Diagnosis of Thoracic Outlet

Physical exam

Diagnosis of Thoracic Outlet

Physical exam
Adson or Scalene 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 indicated by a disappearance of the pulse.

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.

Caveat: Change in pulse amplitude in up to 53% of normal volunteers

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Arterial TOS
Upper extremity embolization Pulsatile supraclavicular mass Sudden onset arm ischemia

Arterial TOS: Uniformly straightforward with good results

Arterial injuries in the thoracic outlet syndrome
Joseph 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

Arterial injuries in the thoracic outlet syndrome
Joseph 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.

Compression of the axillary artery by the humoral head with repetitive stress in certain athletes (mainly pitchers) 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-up examination (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 Indwelling Hickman catheter Paget Schroetter syndrome

Axillo-subclavian vein thrombosis

Effected arm swelling

Standard approach to PagetSchroetter

Venogram in adduction and abduction If symptoms are chronic and subclavian vein occluded-no therapy If symptoms acute and occlusion/thrombus can be 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

Approach to venous thoracic outlet: significant variance The aggressive

First Rib Resection and Scalenectomy for Chronically Occluded Subclavian Veins: What Does It Really Do?
Ricardo de Leon, David C. Chang, g Christopher p Busse, Diana Call, and Julie Ann Freischlag, Baltimore, Maryland

Post thrombolysis Subclavian vein Patent w/ stenosis

Four patients with chronic, symptomatic subclavian vein occlusion All re-opened after first rib resection Average of 7 months to recanalization

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

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

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 9 9 of f 22 patients ti t (41%) did not t require i 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 surgical intervention. No chronic anticoagulation J Vasc Surg. 2000 Jul;32(1):57-67

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

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 syndrome
Paul 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

25 consecutive patients with thrombolysis, thrombolysis first rib resection and intra-op 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

23 patients with thrombolysis, first rib resection, and immediate venography 14 pts w/ residual vein stenosis (>50%) after PTA underwent subclavian vein stenting All PTA are patent, with a mean follow-up of 4 years (range, 2-6 years). 9 of 14 stents patent, with a mean follow-up of 3.5 years Conclusion
Patients with short-segment venous strictures after successful lysis and thoracic outlet decompression may safely be treated with subclavian venous stents and can expect long-term patency

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Peri-procedural Angioplasty
Post angioplasty

Neurogenic TOS: Etiology

Combination of predisposing anatomic factors and previous neck trauma Brachial plexus in the thoracic outlet may be compressed with normal activity Activities involving sustained or repeated elevation of the arm or vigorous turning of the neck may place additional tension on the , thereby y potentiating p g any yp positional compression p of scalene muscles, the underlying nerve roots. This anatomic predisposition worsened by congenital variants
such as scalene muscle variations abnormal tendinous bands cervical rib

Most patients with neurogenic TOS describe some form of previous trauma to the head, neck, or upper extremity, followed by a variable interval before the onset of progressive upper extremity symptoms
Post rib resection

Anatomic changes in Thoracic Outlet Syndrome

Human skeletal muscle
type 2 fibers
predominant Quick reacting Low oxidative enzyme capacity

Type 1 fibers
Smaller percentage Slow tonic contracting Greater oxidative capacity Common in postural muscle groups

Anatomic changes in Thoracic Outlet Syndrome

Anterior scalene muscle
Demonstrates type 1 fiber predominance

Histopathology

Thoracic Outlet Syndrome

Increase in type 1 fibers Selective hypertrophy of Type 1 fibers Chronic scalene contraction with constriction of brachial plexus

Increase in connective tissue nodes

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Symptoms of Neurogenic TOS

The primary symptoms of neurogenic TOS are
pain, dysesthesias, numbness, and weakness

Thoracic Outlet SyndromeElectrophysiology

Various tests suggest compression of inferior brachial plexus Ulnar nerve conduction velocities Somatosensory evoked potentials EMG

symptoms usually occur throughout the affected hand or arm

without any localization to a specific peripheral nerve distribution distribution, often involve different areas of the entire upper extremity. Classically more severe in an ulnar distribution

Extension of symptoms from the hand to the shoulder, neck, and upper back is not uncommon, and in many patients, the symptoms in the neck or upper back most patients with neurogenic TOS have symptoms affecting just one upper extremity,
bilateral symptoms however are not uncommon

Main Value of electrophysiologic studies is to rule out other causes of vague symptoms Carpal Tunnel Ulnar nerve entrapment Cervical nerve root compression

Diagnosis of Thoracic Outlet

Based primarily on history/physical exam Supported by CXR/Electrophysiology Confirmed by Scalene block Often remains ambiguous despite extensive work-up

Thoracic Outlet Syndrome

Scalene block

Selective Botulinum Chemodenervation of the Scalene Muscles for Treatment of Neurogenic Thoracic Outlet Syndrome
Sheldon E. Jordan MD, Samuel S. Ahn MD, Julie A. Freischlag MD, Hugh A. Gelabert MD and Herbert I. Machleder MD

22 patients with clinical neurogenic TOS Injection I j i of f 100u 100 B Botox i in 1 1ml l saline li Control group with lidocaine/steroid 64% of botox group with relief at 1 mo 18% of lidocaine group with relief Botox recommended for treatment prior to decompression Ultrasound localization of anterior scalene Injection of 2cc .5% bupivicaine Assess for immediate relief of symptoms

Ann Vasc Surg. 2000 Jul;14(4):365-9

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Conservative criteria for surgical intervention

Classic Physical exam findings Failed 3-6 month trial of Physical therapy Neurology N l rules l out t other th causes cervical radiculopathy Scalene block relieves symptoms Not on Workmans comp.

Operative Options
First rib resection Scalenectomy Claviculectomy Cervical rib resection Brachial plexus neurolysis

Recurrent TOS
Supraclavicular approach Anterior/middle scalene resection if not previously done First Fi t rib ib resection ti if not t previously i l d done Complete neurolysis

Results of Surgery: highly variable

The Good
Reported In-Hospital Complications following Rib Resections for Neurogenic Thoracic Outlet Syndrome
David C. C Chang, Chang Anne O O. Lidor Lidor, Susanna L L. Matsen Matsen, and Julie A A. Freischlag Freischlag, Baltimore, Maryland

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
Ann Vasc Surg. 2007 Sept;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

Results of Surgery
The bad
Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients
Gregory J. Landry, MD, Gregory L. Moneta, MD, Lloyd M. Taylor, Jr, MD, James M. Edwards, MD, and John M. Porter, MD, Portland, Ore

70 patients operated on for neurogenic or venous TOS All completed SF SF-12 12 and DASH (Disability arm , hand hand, shoulder) surveys pre and post-op Significant improvement in scores at 24 months post-op

79 9 patients i with i h neurogenic i 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

JVS Volume 49, Issue 3, March 2009, Pages 630-637

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TOS and Workmans Comp: The Really Bad

Outcome of surgery for thoracic outlet syndrome in Washington state workers compensation
Gary M. Franklin, MD; Deborah Fulton-Kehoe, MPH; Cynthia Bradley, MS, MPH; and Terri Smith-Weller, MN

First Rib Resection Operative Approaches

Transaxillary
Cosmetically appealing Avoids venous collaterals More difficult to do neurolysis or arterial reconstruction

Highlights (Lowlights) 158 Pts. Operated for TOS 60% still disabled at one year 70% with significant limitations Significantly less lost work days in conservatively managed patients 30% with an acute complication 17% with a new neurologic complaint after surgery

Supraclavicular
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.

Transaxillary Approach

The cut end of the first rib is visible between the subclavian artery and brachial plexus

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 Three distinct presentations presentationsarterial, arterial venous 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 Presentation

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

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