Bilateral first rib resection and scalenectomy is effective for treatment of thoracic outlet syndrome

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Abstract

Objective:

Because of the small numbers of thoracic outlet syndrome (TOS) patients treated with bilateral first rib resection and scalenectomy (FRRS), this patient subset has not been well studied. We examined a large cohort of TOS patients who underwent bilateral FRRS to evaluate patient characteristics and outcomes.

Methods:

Patients treated with bilateral FRRS at Johns Hopkins Medical Institutions from 2003 to 2012 were identified by review of a prospectively maintained database. Statistical analysis compared patients with unilateral and bilateral FRRS and bilateral patients with different TOS indications.

Results:

Fifty-three patients underwent bilateral FRRS with a mean follow-up of 11.4 months. Average time between operations was 17.0 months (range, 5.1-59.8 months). Compared with 408 unilateral FRRS patients, bilateral patients were younger (30 vs 35 years; P = .012), with no significant difference in gender. Among patients with dual-sided FRRS, 25 (47%) had bilateral neurogenic symptoms, 2 (4%) had bilateral arterial symptoms, and 26 (49%) had venous symptoms with the first side due to intermittent compression in 5 (second side: four, intermittent compression; one, neurogenic) and effort thrombosis in 21 (second side: 9, effort thrombosis; 8, intermittent compression; 4, neurogenic). Ten patients had prophylactic FRRS to prevent contralateral venous or arterial thrombosis, and eight had cervical ribs. Compared with neurogenic patients, venous patients were younger (25 vs 35 years; P < .001), with a trend toward more competitive athletes (seven venous vs two neurogenic). Symptomatic restenosis requiring dilation occurred after four FRRS for venous symptoms at a mean of 32.4 months, and rethrombosis occurred after four FRRS at a mean of 4 weeks (one treated with warfarin, three with tissue plasminogen activator), all on the primary side. Overall, 88% of FRRS for symptomatic TOS led to resolved symptoms at last follow-up.

Conclusions:

Bilateral FRRS is an effective method for treatment of TOS. Venous bilateral patients more often are younger, are competitive athletes, and require close postoperative monitoring for recurrent stenosis and thrombosis.

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