A Fourteen-Year Experience with Vascular Anomalies Encountered during Transaxillary Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: Transaxillary approach to first rib resection and scalenectomy (TAFRRS) is a well-established technique for treatment of thoracic outlet syndrome (TOS). Although anatomic features encountered during TAFRRS are in general constant, vascular anomalies may be encountered but have not been described to date. Herein we describe vascular abnormalities encountered during TAFRRS. METHODS: We performed a retrospective review of a prospective practice database of 224 operations for TOS performed in 172 patients from March 2000 to March 2014. We excluded 10 patients with missing operative reports, 3 reoperations on the same patient, and 8 non-transaxillary resections. We recorded vascular anomalies identified in operative reports and reviewed computed tomography imaging to delineate the nature of these abnormalities. RESULTS: The overall incidence of vascular anomalies was 11% (22 of 203 TAFRRS). Most patients with anomalies had venous TOS (vTOS) (9 patients, 41%), followed by 7 (32%) with neurogenic TOS (nTOS). The remainder of the patients had arterial TOS (aTOS) (6 patients, 27%). Seven patients (32%) had an abnormal subclavian artery (SCA) with 5 (23%) having an abnormal arterial course in the anterior scalene muscle (ASM); 6 patients (27%) had an abnormal internal mammary artery (IMA) originating from distal SCA; 4 (18%) had abnormalities in the supreme thoracic artery (bifurcation or duplication); 2 (9%) had an abnormal branch from the SCA with anomalous location in the operative field; and 3 (14%) had an abnormal large venous branch penetrating the ASM. In the 19 patients with arterial anomalies, 8 (42%) were recognized as arterial branches penetrating the ASM, and 11 (58%) were noticed as they had anomalous arterial locations within the operative field. Most arterial anomalies were seen in vTOS (9, 45%), followed by nTOS (7, 35%). No intraoperative vascular complications occurred. Perioperative complications included 1 occurrence of postoperative transfusion for bleeding following axillary drain discontinuation and 2 Horner's syndromes. One aberrant IMA was electively ligated to allow complete thoracic outlet decompression. CONCLUSIONS: Arterial anomalies during TAFRRS are encountered in 11% of operations, and may present with vessel locations in unusual areas within the operative field, or as abnormal vessels penetrating the ASM, thus making scalenectomy precarious. Careful attention must be paid to possible abnormal locations of vessels in the thoracic outlet to avoid bleeding complications.

Computed tomography-guided reoperation for neurogenic thoracic outlet syndrome.

OBJECTIVE: Persistent or recurrent symptoms after surgical treatment for neurogenic thoracic outlet syndrome (nTOS) is a problem commonly encountered by high-volume referral centers. The mechanical etiology patterns at reoperation include (1) inadequate previous rib resection, (2) rib regrowth, (3) scar tissue formation, or (4) intact scalene muscle. Reoperative TOS surgery has significant potential morbidity, and therefore, careful patient selection and meticulous planning are required. This study evaluated the utility of multidetector computed tomography (CT) in the differential diagnosis of patients with recurrent or persistent nTOS. METHODS: A retrospective record review was performed of a nTOS referral practice of patients treated from 2003 to 2012 to focus on patients reoperated on for recurrent or persistent symptoms. In 2003, a dedicated high-resolution multidetector TOS CT protocol was established to assist in clinical decision making and reoperative planning. A single designated radiologist interpreted all CT images. Imaging, patient clinical characteristics, interventions, and outcomes were reviewed. RESULTS: The study group included 20 reoperations for recurrent (n = 15) or persistent (n = 5) symptoms. Mean age was 35 years, and 60% of redo cases were in women. Preoperative CT imaging demonstrated the following anatomic patterns: inadequate previous rib resection in 5 (25%), rib regrowth in 5 (25%), scar tissue formation in 10 (50%), and intact scalene muscle in 3 (15%). Operative findings concurred with preoperative imaging in 85% of patients. There were no neurovascular injuries and no major complications. At a mean follow-up of 43 months, improvement or resolution of symptoms was significant in nine patients (45%), moderate in seven (35%), and minimal in four (20%). CONCLUSIONS: Recurrent/persistent nTOS is an often-vexing problem with challenging solutions. These results demonstrate the utility of a TOS protocol CT scan in providing correlative objective findings and in assisting with reoperative planning. Positive radiographic findings that correlate with patient symptoms inform the decision to reoperate.

Acute ischemia after revision hallux valgus surgery leading to amputation.

Acute arterial insufficiency after revision hallux valgus surgery is a rare complication. The identification of surgical candidates who are at risk of vascular complications is of utmost importance. The patient-reported symptoms and physical findings combined with noninvasive vascular studies are generally reliable to assess the vascular status but can fail to identify patients with atypical disease patterns. We present the case of a patient with normal pulses who underwent revision hallux valgus surgery, leading to gangrene of the hallux that required transmetatarsal amputation. We reviewed the vascular evaluation methods and causes of acute ischemia after surgery, including vasculitis.

Transmetatarsal amputation in the setting of antiphospholipid antibody syndrome.

Antiphospholipid syndrome is a hypercoagulable disease that can present foot and ankle surgeons with a unique challenge in treating patients who present with thrombosis and ischemia despite having normal pedal pulses. Appropriate perioperative management is imperative in these patients, because limb- and life-threatening complications can occur postoperatively, despite aggressive anticoagulation. We present the case of a 46-year-old male who underwent a transmetatarsal amputation and, despite aggressive therapy, developed a myriad of complications postoperatively. At 10 months postoperatively, the patient was doing well in an accommodative orthotic with minimal pain while receiving continued aggressive therapy and follow-up examinations by a number of specialists to treat his antiphospholipid syndrome.

Choosing Surgery for Neurogenic TOS: The Roles of Physical Exam, Physical Therapy, and Imaging.

Neurogenic thoracic outlet syndrome (nTOS) is characterized by arm and hand pain, paresthesias, and sometimes weakness resulting from compression of the brachial plexus within the thoracic outlet. While it is the most common subtype of TOS, nTOS can be difficult to diagnose. Furthermore, patient selection for surgical treatment can be challenging as symptoms may be vague and ambiguous, and diagnostic studies may be equivocal. Herein, we describe some approaches to aid in identifying patients who would be expected to benefit from surgical intervention for nTOS. We describe the role of physical examination, physical therapy, and imaging in the evaluation and diagnosis of nTOS.

Etiology of neurogenic thoracic outlet syndrome.

The anatomic problems that lead to TOS are now well known. They consist of congenital anomalies that are superimposed on some form of trauma. There are some promising technologies that offer hope of early anatomic diagnosis. Sophisticated imaging of the brachial plexus as advocated by Collins offers hope. High resolution multidetector CT scanning seems even more promising.

Diagnosing thoracic outlet syndrome.

Diagnosing and treating thoracic outlet syndrome can be challenging and frustrating. It must be emphasized that the diagnosis of TOS is a clinical one based on a detailed history and physical examination. This takes time and effort and is often confounded by the patient's research on the internet and emotional problems usually resulting from the symptoms and lack of appropriate treatment. Years of inappropriate diagnosis and ineffective therapy take a heavy toll on these patients. Some have psychologic problems to the point that no treatment, no matter how well indicated, will make them well. Some have had symptoms so long that there is permanent neurologic damage. Each patient presents his or her own diagnostic challenge. Solving the problem and providing effective therapy can be rewarding for doctor and patient.

Appendix: use of multidetector CT and three-dimensional reconstructions in thoracic outlet syndrome: a preliminary report.

Contrast-enhanced CT using a multidetector array, multiplanar reformatting, and three-dimensional reconstruction holds great promise in defining the anatomic findings in patients suspected of having thoracic outlet syndrome.

Reverse sural artery flap for the reconstruction of chronic lower extremity wounds in high-risk patients.

Soft tissue defects in patients with chronic comorbidities place these patients at high risk for amputation, even when their underlying problems are controlled. The reverse sural artery flap is an effective technique for closing these defects and saving the limb. We retrospectively reviewed 15 consecutive high-risk patients who underwent a sural artery flap procedure between 2003 and 2005 as a final attempt to prevent having a below-the-knee amputation. All of our patients presented with at least 1 comorbidity, with a majority having multiple. Comorbidities in our patient population consisted primarily of diabetes mellitus with neuropathy, critical limb ischemia, end-stage renal disease, and various cardiomyopathies. All patients presented before surgical intervention with a longstanding history of chronic ulcerations that had failed multiple healing strategies. Ulcerations were located at various regions of the foot and ankle such as the heel, lateral malleolus, medial malleolus, and the lateral midfoot. Of those 15 procedures, three failed completely and two had complete dermal necrosis with viable adipose tissue that healed secondarily. The remaining ten flaps healed primarily. We used negative pressure therapy preoperatively in seven patients and postoperatively in five patients. We obtained a success rate of 80%. The reverse sural artery flap has many advantages over free flaps, which has made it a viable treatment option in chronic ulcerations that have failed conservative attempts.