Authors
Shubin A.A.1, Karpov A.A.1, Magomadov Ya.U.1, Parkin P.N.1, 2, Fataliev G.B.1
1 Botkin City Clinical Hospital, Moscow
2 I.M. Sechenov First Moscow State Medical University, Moscow
Abstract
Rationale. Given the rarity of the pathology, the risks associated with it, and the variability of treatment methods, as well as the absence of similar reported cases in scientific databases, we found it necessary to share our experience in treating a patient with thoracic outlet syndrome in combination with an additional cervical rib on the left, aneurysm of the left subclavian artery, thrombosis of the subclavian and axillary arteries on the left, and critical ischemia of the left upper limb.
Objective: demonstration of a case of surgical treatment of a patient with thoracic outlet syndrome in combination with aneurysm of the left subclavian artery, thrombosis of the subclavian, axillary and brachial arteries on the left, critical ischemia of the left upper limb.
Methods. A 36-year-old woman was admitted to the vascular surgery department complaining of pain in her left upper limb at rest, numbness and coldness of the fingers of her left hand. During the examination, according to the results of multispiral computed tomography with intravenous contrast, additional cervical ribs, compression of the left subclavian artery by the median stair muscle, occlusion of the left subclavian, axillary and brachial arteries, as well as an aneurysm of the left subclavian artery measuring 11x15 mm are determined.
Results. Resection of the accessory cervical rib, resection of the subclavian artery aneurysm with autovenous prosthetics, and arterio-arterial plasty of the brachial artery on the left were performed. The postoperative period was complicated by thrombosis of the brachial artery in the middle and distal third of the shoulder on the left, and therefore thrombectomy was performed from the arteries of the left upper limb, resection of the distal third of the brachial artery with autovenous prosthetics on the left. In the control multispiral computed tomography with intravenous contrast, the autovenous prosthesis is passable. The brachial, ulnar, and radial arteries contrast homogeneously throughout.
Conclusion. The above clinical case demonstrates the successful result of simultaneous surgical treatment of a patient with thoracic outlet syndrome combined with an additional cervical rib, subclavian artery aneurysm and arterial thrombosis of the left upper limb. The arterial form of thoracic outlet syndrome is the rarest of the described, but it can be the most dangerous in the prospect of limb preservation. With untimely surgical treatment, the aneurysm lumen may thrombose and cause embolization of the distal bed with a clinical picture of acute limb ischemia.
Keywords: thoracic outlet syndrome, subclavian artery aneurysm, cervical ribs.
References
1. Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome. Hand Clin. 2004; 20(1): 27-36. doi: 10.1016/ s0749-0712(03)00080-5.
2. Buller LT, Jose J, Baraga M, et al. Thoracic Outlet Syndrome: Current Concepts, Imaging Features, and Therapeutic Strategies. Am J Orthop (Belle Mead NJ). 2015; 44(8): 376-382.
3. Ferrante MA. The thoracic outlet syndromes. Muscle Nerve. 2012; 45(6): 780-795. doi: 10.1002/mus.23235.
4. Laulan J, Fouquet B, Rodaix C, et al. Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. J Occup Rehabil. 2011; 21(3): 366-373. doi: 10.1007/s10926-010-9278-9.
5. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007; 46(3): 601-604. doi: 10.1016/j.jvs. 2007.04.050.
6. Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways. Man Ther. 2009; 14(6): 586-595. doi: 10.1016/j.math. 2009.08.007.
7. Murtazina AF, Nikitin SS, Naumova ES. Thoracic outlet syndrome: clinical and diagnostic features. Neuromuscular Diseases. 2017; 7(4): 10-19. (In Russ.) doi: 10.17650/2222-8721-2017-7-4-10-19.
8. Grunebach H, Arnold MW, Lum YW. Thoracic outlet syndrome. Vasc Med. 2015; 20(5): 493-495. doi: 10.1177/1358863X15598391.
9. Peet RM, Henriksen JD, Anderson TP, et al. Thoracic-outlet syndrome: evaluation of a therapeutic exercise program. Proc Staff Meet Mayo Clin. 1956; 31(9): 281-287.
10. Masocatto NO, Da-Matta T, Prozzo TG, et al. Thoracic outlet syndrome: a narrative review. Síndrome do desfiladeiro torácico: uma revisão narrativa. Rev Col Bras Cir. 2019; 46(5): e20192243. doi: 10.1590/0100-6991e-20192243.
11. DiLosa KL, Humphries MD. Epidemiology of thoracic outlet syndrome. Semin Vasc Surg. 2021; 34(1): 65-70. doi: 10.1053/j.semvascsurg.2021.02.008.
12. Landry GJ, Moneta GL, Taylor LM Jr, et al. Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. J Vasc Surg. 2001; 33(2): 312-319. doi: 10.1067/mva.2001.112950.
13. Machanic BI, Sanders RJ. Medial antebrachial cutaneous nerve measurements to diagnose neurogenic thoracic outlet syndrome. Ann Vasc Surg. 2008; 22(2): 248-254. doi: 10.1016/ j.avsg.2007.09.009.
14. Aslanukov MN, Vasiliev SA, Kuklin AV, et al. Surgical treatment of a patient with bilateral brachioplexopathy due to cervical ribs. Clinical and Experimental Surgery. Petrovsky Journal. 2024; 12(4): 110-4. (In Russ.) doi: 10.33029/2308-1198-2024-12-4-110-114.
15. Atasoy E. Thoracic outlet compression syndrome. Orthop Clin North Am. 1996; 27(2): 265-303.
16. Laulan J. Thoracic outlet syndromes. The so-called «neurogenic types». Hand Surg Rehabil. 2016; 35(3): 155-164. doi: 10.1016/j.hansur.2016.01.007.
17. Lapegue F, Faruch-Bilfeld M, Demondion X, et al. Ultrasonography of the brachial plexus, normal appearance and practical applications. Diagn Interv Imaging. 2014; 95(3): 259-275. doi: 10.1016/j.diii.2014.01.020.
18. Sultanov DD, Tukhtaev FM, Kurbanov NR, et al. Syndrome of upper thoracic aperture. Avicenna Bulletin. 2014; 3(60): 121-127. (In Russ.)
19. Kuhn JE, Lebus V GF, Bible JE. Thoracic outlet syndrome. J Am Acad Orthop Surg. 2015; 23(4): 222-232. doi: 10.5435/JAAOS-D-13-00215.
20. Daniels B, Michaud L, Sease F Jr, et al. Arterial thoracic outlet syndrome. Curr Sports Med Rep. 2014; 13(2): 75-80. doi: 10.1249/ JSR.0000000000000034.
21. Moore R, Wei Lum Y. Venous thoracic outlet syndrome. Vasc Med. 2015; 20(2): 182-189. doi: 10.1177/1358863X14568704.
22. Franklin GM. Work-Related Neurogenic Thoracic Outlet Syndrome: Diagnosis and Treatment. Phys Med Rehabil Clin N Am. 2015; 26(3): 551-561. doi: 10.1016/j.pmr.2015.04.004.
23. Bondarev VI, Kyandaryan AK, Ablitsov NP, et al. Dynamic and functional tests in the diagnosis and treatment of compression stenoses of the peripheral arteries. Bulletin of Surgery named after I.I. Grekov. 1994; 152(1-2): 127-8. (In Russ.)
24. Gillard J, Pérez-Cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001; 68(5): 416-424. doi: 10.1016/s1297-319x(01)00298-6.
25. Zurkiya O, Ganguli S, Kalva, SP, et al. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. J Am Coll Radiol. 2020; 17(5S): S323-S334. doi: 10.1016/j.jacr.2020.01.029.
26. Hussain MA, Aljabri B, Al-Omran M. Vascular Thoracic Outlet Syndrome. Semin Thorac Cardiovasc Surg. 2016; 28(1): 151-157. doi: 10.1053/j.semtcvs.2015.10.008.
27. Cormier JM, Amrane M, Ward A, et al. Arterial complications of the thoracic outlet syndrome: fifty-five operative cases. J Vasc Surg. 1989; 9(6): 778-787.
28. Demondion X, Herbinet P, Van Sint Jan S, et al. Imaging assessment of thoracic outlet syndrome. Radiographics. 2006; 26(6): 1735-1750. doi: 10.1148/rg.266055079.
29. Scher LA, Veith FJ, Samson RH, et al. Vascular complications of thoracic outlet syndrome. J Vasc Surg. 1986; 3(3): 565-568. doi: 10.1067/mva.1986.avs0030565.
30. Likes K, Dapash T, Rochlin DH, et al. Remaining or residual first ribs are the cause of recurrent thoracic outlet syndrome. Ann Vasc Surg. 2014; 28(4): 939-945. doi: 10.1016/ j.avsg.2013.12.010.
31. Sanders RJ, Pearce WH. The treatment of thoracic outlet syndrome: a comparison of different operations. J Vasc Surg. 1989; 10(6): 626-634. doi: 10.1067/mva.1989.15575.
32. Cheng SW, Reilly LM, Nelken NA, et al. Neurogenic thoracic outlet decompression: rationale for sparing the first rib. Cardiovasc Surg. 1995; 3(6): 624. doi: 10.1016/0967-2109(96)82859-6.
33. Nguyen LL, Soo Hoo AJ. Evaluation and Management of Arterial Thoracic Outlet Syndrome. Thorac Surg Clin. 2021; 31(1): 45-54. doi: 10.1016/j.thorsurg.2020.09.006.
