The evolving role of endovascular therapy in the management of arterial thoracic outlet syndrome

Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of...

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Bibliographic Details
Published in:Journal of vascular surgery 2022-03, Vol.75 (3), p.968-975.e1
Main Authors: Pantoja, Joe Luis, Rigberg, David A., Gelabert, Hugh A.
Format: Article
Language:English
Subjects:
Adult
Arterial thoracic outlet syndrome
Blood Vessel Prosthesis Implantation - adverse effects
Blood Vessel Prosthesis Implantation - trends
Databases, Factual
Decompression, Surgical - adverse effects
Decompression, Surgical - trends
Endovascular Procedures - adverse effects
Endovascular Procedures - trends
Female
Humans
Male
Middle Aged
Physician's Role
Postoperative Complications - etiology
Practice Patterns, Physicians' - trends
Recovery of Function
Retrospective Studies
Subclavian Artery - diagnostic imaging
Subclavian Artery - physiopathology
Subclavian Artery - surgery
Subclavian artery bypass
Subclavian artery stenting
Surgeons - trends
Thoracic Outlet Syndrome - diagnostic imaging
Thoracic Outlet Syndrome - physiopathology
Thoracic Outlet Syndrome - surgery
Time Factors
Treatment Outcome
Young Adult
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Summary:Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery. We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, January 1986 to August 2003 (P-1) vs September 2003 to March 2021 (P-2), and by treatment modality, open vs endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups. Of 2200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Compared with open aneurysmal repair, endovascular stent graft repairs took less time (241 vs 330 minutes; P = .09), incurred lower estimated blood loss (103 vs 150 mL; P = .36), and had a shorter length of stay (2.4 vs 5.0 days; P = .10). Yet the endovascular group had decreased primary (63% vs 77%; P = .481), primary assisted (75% vs 85%; P = .590), and secondary patency rates (88% vs 92%; P = .719), at a mean follow-up time of 3.0 years for the endovascular group and 6.9 years for the open group (P = .324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased postoperatively, 2.9 vs 0.8 (P = .015) and 42.6 vs 12.6 (P = .004), respectively. This study describes the evolving role of endovascular management of ATOS over the past two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single in
ISSN:0741-5214
1097-6809
DOI:10.1016/j.jvs.2021.10.024