Arterial complications of thoracic outlet syndrome (TOS) are rare (<1%). Surgery involves decompression of thoracic outlet, repair of subclavian aneurysm, and often embolectomy. Most published series have reported interposition graft for repair of subclavian aneurysm. The objective of this study was to evaluate the long-term results of decompression and direct repair of subclavian artery aneurysm in arterial TOS.

This is a retrospective review of a prospectively maintained database. All patients who underwent surgery for arterial TOS from January 2001 to August 2019 were included. Patients' demographics, presentation, treatment, and outcomes were reviewed. Direct repair of subclavian artery aneurysm included longitudinal arteriotomy, intimectomy (excision of ulcerated intima), and tailoring.

There were 74 operations performed on 65 patients for arterial TOS. Mean age at presentation was 33.62 years (range, 13-69 years). The female to male ratio was 1.5:1.0. There were 12 patients with bilateral arterial TOS, although all presented with unilateral symptoms. Three patients presented with acute limb ischemia. The remaining patients had delayed presentation of acute ischemia (range, 30 days-2 years), including neck pain and swelling (10), upper limb claudication (45), rest pain and digital cyanosis (10), and posterior circulation stroke (1). The cause of arterial TOS was complete cervical rib alone in 60 patients (12 bilateral), cervical and first rib in 2 patients, incomplete first rib in 2 patients, and compression with scalenus anticus alone in 1 patient. All 12 asymptomatic TOS patients showed arterial compression, and 3 patients refused surgery for the asymptomatic limb. Surgery included thoracic outlet decompression by anterior scalenotomy (74), excision of cervical rib (71), and excision of first rib (4). Of the 74 operations performed 60 included direct repair of subclavian aneurysm, 2 resection and end-to-end anastomosis and 3 interposition grafts. 9 asymptomatic dilatations did not need arterial repair. Trans-subclavian embolectomy was done in 53 and trans-brachial in 31 patients. Early complications included haemothorax requiring chest drain (1), lymph leak due to thoracic duct injury requiring re-exploration and ligation (1), phrenic nerve paresis (2), and brachial neurapraxia (2). Mean follow-up was 2.8 years (range 6 months-8 years); 13 patients were lost to follow-up after 6 months. Follow-up is at regular intervals clinically and with duplex ultrasound scan in the clinic. One patient has persistent brachial neuralgia at 3 years and is responsive to medication. Asymptomatic dilation of directly repaired subclavian artery was identified in one patient at 18 months of follow-up, and he is under surveillance. All other directly repaired 59 subclavian arteries are patent and appear normal on duplex.

Direct repair of subclavian artery aneurysm in arterial TOS patients can be performed safely with good long term results. Recurrent dilation is rare and can be managed conservatively.

1. Maru S, Dosluoglu H, Dryjski M, Cherr G, Curl GR, Harris LM. Thoracic outlet syndrome in children and young adults. Eur J Vasc Endovasc Surg 2009;38:560-4. 2. Short DW. The subclavian artery in 16 patients with complete cervical ribs. J Cardiovasc Surg (Torino) 1975;16:135-41. 3. Vemuri C, McLaughlin LN, Abuirqeba AA, Thompson RW. Clinical presentation and management of arterial thoracic outlet syndrome. J Vasc Surg 2017;65:1429-39. 4. Cormier JM, Amrane M, Ward A, Laurian C, Gigou F. Arterial complications of the thoracic outlet syndrome: Fifty-five operative cases. J Vasc Surg 1989;9:778-87. 5. Reporting Standards of the Society for Vascular Surgery for thoracic outlet syndrome. Karl A Illig, Dean Donahe, Audra Duncan, Julie Freischlag, Hugh Gelabert, Kaj Johansen et al. J Vasc Surg 2016;64:e23-e35.