Systematic Review on Botulinum Toxin Injections as Diagnostic or Therapeutic Tool in Thoracic Outlet Syndrome.

BACKGROUND: The optimal diagnostic and treatment algorithm for patients with suspected thoracic outlet syndrome (TOS) remains challenging. Botulinum toxin (BTX) muscle injections have been suggested to shrink muscles in the thoracic outlet reducing neurovascular compression. This systematic review evaluates the diagnostic and therapeutic value of BTX injections in TOS. METHODS: A systematic review of studies reporting BTX as a diagnostic or therapeutic tool in TOS (or pectoralis minor syndrome as TOS subtype) was conducted in PubMed, Embase, and CENTRAL databases on May 26, 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. Primary end point was symptom reduction after primary procedure. Secondary end points were symptom reduction after repeated procedures, the degree of symptom reduction, complications, and duration of clinical effect. RESULTS: Eight studies (1 randomized controlled trial [RCT], 1 prospective cohort study, and 6 retrospective cohort studies) were included reporting 716 procedures in at least 497 patients (at minimum 350 primary and 25 repeated procedures, residual unclear) diagnosed with presumably only neurogenic TOS. Except for the RCT, the methodological quality was fair to poor. All studies were designed on an intention to treat basis, one also investigated BTX as a diagnostic tool to differentiate pectoralis minor syndrome from costoclavicular compression. Reduction of symptoms was reported in 46-63% of primary procedures; no significant difference was found in the RCT. The effect of repeated procedures could not be determined. Degree of symptom reduction was reported by up to 30-42% on the Short-form McGill Pain scale and up to 40 mm on a visual analog scale. Complication rates varied among studies, no major complications were reported. Symptom relief ranged from 1 to 6 months. CONCLUSIONS: Based on limited quality evidence, BTX may provide short-lasting symptom relief in some neurogenic TOS patients but remains overall undecided. The role of BTX for treatment of vascular TOS and as a diagnostic tool in TOS is currently unexploited.

Aortic neck angulations decrease during and after endovascular aneurysm repair.

PURPOSE: To investigate whether suprarenal and infrarenal aortic neck angles change immediately after endovascular aneurysm repair (EVAR) or during follow-up. A change in aortic angulation influences the proximal stent-graft sealing and fixation zone, thereby possibly influencing the long-term results of EVAR. METHODS: Forty-three EVAR patients (39 men; mean age 73 years, range 62-85) with preoperative, postoperative, and 1, 2, and 3-year follow-up computed tomographic angiography (CTA) data were selected from our center's vascular database. The suprarenal and infrarenal angulations on all CTAs were measured using a standardized 3-dimensional centerline method, which has a repeatability coefficient of 6.4° (20.2%) for the suprarenal angle and 6.2° (13.4%) for the infrarenal angle. Repeated measures analysis was used to test the effect of angulation over time, followed by a post-hoc analysis. RESULTS: The mean suprarenal angulation was 28°±16° preoperatively, 22°±16° postoperatively, 19°±15° after 1 year, 17°±14° after 2 years, and 16±13° after 3 years (mean difference 5°, 9°, 11°, and 12°, respectively). The aortic suprarenal angle decrease was significant (all p<0.01) compared with the preoperative measurements at all time points. The mean infrarenal angulation was 50°±18° preoperatively and changed to 41°±15° postoperatively, to 39°±14° after 1 year, to 38°±14° after 2 years, and to 36°±14° after 3 years (mean difference 8°, 11°, 11° and 13°, respectively). The infrarenal aortic angle decrease was significant (all p<0.01) compared with the preoperative measurements at all time points. CONCLUSION: The aortic suprarenal and infrarenal angles decrease during EVAR and in the years after this procedure.