Boney abnormalities cause arterial, venous, and/or neurogenic thoracic outlet syndrome.

Background: Thoracic outlet syndrome (TOS) is a rare condition caused by compression of the neurovascular structures within the thoracic outlet. Different classifications of TOS exist depending on the neurovascular structure being compressed: neurogenic, venous, or arterial. Any of these forms can present independently or coexist with one other. TOS symptoms are sometimes precipitated by the presence of boney abnormalities that often require surgical intervention for ultimate resolution. This retrospective review will examine the presentations and outcomes of patients with TOS whose cause was a boney abnormality. Methods: A total of 73 patients who underwent thoracic outlet surgery between 2016 and 2021 were retrospectively reviewed via electronic medical records. Twelve (16%) patients demonstrated boney abnormalities on presentation causing their symptoms. The patients with boney abnormalities were analyzed based on venous, arterial, or neurogenic TOS diagnosis. Results: Of the 12 patients with boney abnormalities, 5 were classified as venous TOS, 6 patients as neurogenic TOS, and 1 as arterial TOS. The boney abnormalities were as follows: venous TOS: three clavicular fractures, one nonfused congenital clavicle, and one residual rib; neurogenic TOS: three fractured first ribs, one fractured clavicle, and two cervical ribs; and arterial TOS: fused first and second rib with bilateral cervical ribs and arterial compression. Postoperatively, there were no artery, vein, or nerve injuries. Five patients had a pneumothorax treated over night with a chest tube, and one patient had a superficial wound infection. The median hospital stay was 1 day. All patients completed physical therapy after surgery. All patients have symptom resolution at follow-up. Conclusions: Patients with boney abnormalities constitute about one-fifth of patients who can present with all three forms of TOS: neurogenic, arterial, and venous, and some will have more than one of these presentations. Results in patients undergoing surgery with boney abnormalities causing thoracic outlet syndrome are excellent with symptom resolution and without substantial complications.

Excellent results seen with both transaxillary and infraclavicular approaches to first rib resection in patients with subclavian vein thrombosis.

BACKGROUND: Venous thoracic outlet syndrome (VTOS) is a debilitating condition with several well-documented treatment paradigms. We reviewed the outcomes from a large academic institution of patients who had undergone transaxillary first rib resection with delayed venography (TA) or infraclavicular first rib and subclavius muscle resection with concomitant venography (ICV) for VTOS with subclavian vein thrombosis. METHODS: We performed a retrospective review of the medical records of all patients who had undergone first rib resection and scalenectomy for VTOS with subclavian vein thrombosis at a single academic institution. The demographics, presentation, operative records, and outcomes were collected. Descriptive statistics were used to compare the two groups. RESULTS: A total of 73 patients had undergone first rib resection for VTOS during the study period. Of the 73 patients, 36 (49%) had presented with thrombosis of the subclavian vein and were included in the present review. Of the 36 patients, 26 (72%) had undergone TA and 10 (28%) had undergone ICV. No significant differences were seen between the two groups in female gender (54% vs 50%; P = 1.00) or age (28.7 years vs 29.5 years; P = .88). A higher percentage of the ICV group had undergone preoperative thrombolysis (70% vs 27%; P = .02). All the patients in the ICV group had undergone intraoperative balloon venoplasty at resection. The mean time from thrombosis to resection was 2.3 months. All of the TA group had undergone venography at 2 weeks postoperatively. Venography had revealed 15 stenotic veins requiring venoplasty, 8 widely patent veins, 1 acutely thrombosed vein, and 3 chronically occluded veins. The time from initial thrombosis to surgical intervention was 10 months for the patent group, 6 months for the stenotic group, and 4 months for the occluded group. In the TA group, 19% of the patients had required chest tube placement intraoperatively for pneumothorax. In the ICV group, complications included postoperative hematoma (n = 1), wound infection (n = 1), and hemothorax (n = 1). The mean length of stay was 1.04 days for the TA group and 2.00 days for the ICV group (P < .0001). The mean follow-up was 10.4 months and 15.8 months for the TA and ICV groups, respectively. No mortalities were reported. No differences in the vein patency rates were seen between the two groups at follow-up (TA, 93%; vs ICV, 100%; P = 1.00). All the patients were asymptomatic at follow-up. CONCLUSIONS: The outcomes for the patients who had undergone TA or ICV for subclavian vein thrombosis were excellent with no mortality and few complications. The subclavian vein patency rates were high, and all the patients were asymptomatic at follow-up.

Modifiable risk factors for burnout in vascular surgery trainees.

OBJECTIVE: Burnout is prevalent among vascular surgery trainees. Here we aim to identify modifiable risk factors for burnout in vascular surgery training, to facilitate the development of programs to enhance and sustain trainee well-being. METHODS: The Association of Program Directors in Vascular Surgery issued the Annual Training survey in the fall of 2018 to all trainees. The survey contained items to assess frequency of burnout, as well as mentorship, training environment, and stress coping mechanisms using an abbreviated COPE (Coping Orientation to Problems Experienced) inventory. RESULTS: Of 628 surveys issued, the response rate was 30% (n = 188). Respondents indicated that the majority of programs offer mentorship opportunities (n = 150 [83%]) that are longitudinal throughout the duration of training (n = 140 [77%]). Fifty-eight percent (n = 109) indicated there was an appropriate balance between learning and productivity in their program, with more respondents leaning toward too much clinical productivity (n = 57) and fewer toward too much learning (n = 19). Forty-five percent of respondents indicated feeling burnout at least weekly (n = 81). The burnout group was less likely to report an appropriate balance between clinical productivity and learning (49.4% vs 67.7%; P < .001), as well as a lower frequency of mentorship opportunities (72.1% vs 92.7%; P < .001). Certain coping skills were used more frequently in the burnout group, including self-distraction, disengagement, humor, self-blame, and substance use. In multivariate analysis, frequent use of self-blame conferred a 9.847-fold increased risk (95% confidence interval, 2.114-45.871) of burnout (P = .003), while feeling appropriately challenged by the faculty was significantly protective (odds ratio for burnout, 0.158; 95% confidence interval, 0.031-0.820; P = .03). CONCLUSIONS: The protective effect against vascular surgery trainee burnout conferred by the availability of mentorship suggests that an expansion and emphasis on mentorship in training may help to mitigate trainee burnout. Mentorship may also be a suitable channel to assess for an appropriate level of challenge, as well as for an appropriate balance between clinical productivity and learning that, when present, are also protective against burnout. Furthermore, the correlation between the frequent use of certain coping skills and burnout highlight this as an area for intervention, potentially through a combination of mentor modeling and formal training on healthy stress-related coping strategies.

Routine venography following transaxillary first rib resection and scalenectomy (FRRS) for chronic subclavian vein thrombosis ensures excellent outcomes and vein patency.

To assess the role of postoperative venography in patients treated with first rib resection and scalenectomy (FRRS) for effort thrombosis, a retrospective review was done to evaluate long-term venous patency in 84 patients treated at the Johns Hopkins Medical Institutions. Patients undergo venography 2 weeks postoperatively. If there is >50% stenosis, the subclavian vein is dilated and the patient receives anticoagulation. If the vein is occluded, patients are maintained on anticoagulation. Of the 85 patients, 21 patients had patent veins, 47 patients had stenotic veins, and 16 patients had chronically occluded veins. In follow-up, symptomatic restenosis was seen in 3 patients and those veins were redilated. Two other patients had late occlusions at 23 and 63 months and received anticoagulation and redilatation, respectively. Using venography to guide postoperative management, 79 of 84 patients had patent veins many years postoperatively. Long-term patency, as seen by duplex scan, was achieved in nearly all patients using this protocol.