okluzija vene gornjih ekstremiteta

8/13/2019 Okluzija vene gornjih ekstremiteta

1/15

9/12/20

SVS Comprehensive Vascular Review CourseSeptember 9-10, 2011

Intercontinental Chicago OHare

Subclavian/Axillary lesions

and Thoracic Outlet SyndromeMitchell W. Cox, MD

Disclosure

I have no relationships to disclose.

There is mention of off-label use of medical

devices in my presentation.

Possible Causes of

Subclavian/Axillary Stenosis

Atherosclerosis

Radiation Arteritis

Takayasus

Giant Cell

Trauma

Thoracic Outlet

Presentation

Flow limitation vs. embolic

Innominate

TIA/CVA

Arm Weakness

Subclavian

Steal with vertebrobasilar symptoms

Arm weakness

Hand emboli

Cardiac symptoms S/P LIMA-LAD CABG

Axil lary

Frequent arm symptoms

Possible embolization

62yo female

Heavy smoker Referred for

mild arm

weakness

40mm BP

differential

25yo female with

arm/hand pain

and weakness Pulseless left

arm on PE


2/15

9/12/20

67yo female S/P mastectomy/radiation for

CA

Chronic lymphedema New gangrene of the thumb

Diagnostic Evaluation

Physical exam

Pulses Bruits

Differential Arm pressures

Contrast imaging

CTA

Angiogram

Treatment

Open Surgical

Extra-anatomic

Direct aorto-

innominate/subclavian

Endovascular

Angioplasty and stent

Direct Aorto-subclavian/innominate

Reconstruction

Advantages

Most durable

Primary patency >95% at 5 years

sa van ages

Procedural morbidity

Current status

Rarely used in practice

May be best suited for innominate

lesions/diffuse disease

Reasonable in patient requiring CABG

Direct Bypass OptionsExtra-anatomic

options

Configurations

Ax-Ax

Carotid-carotid

Carotid-subclavian bypassl i i i i Subclavian-carotid transposition

Advantages

Very low procedural Morbidity

Disadvantages

May have compromised inflow in diffuse

disease

Patency may be less Ax-Ax patency as low as 50% at 5yr.


3/15

9/12/20

Angioplasty and Stent

Ideal for proximal subclavian lesions

No encroachment on vertebral or LIMA-LAD No involvement of the thoracic outlet

Balloon-expandable stents

Slight overhang into aorta for oroficial lesions

Marginal stent

candidate

Partially

encroaching

Extending

into thoracic

outlet

58yo male with

right arm

weakness

Vague

dizziness

3v coronary

disease at

cardiac cath

Classic Extra-

Anatomic

67yo female

with ongoing

chest pain

after recent

CABG with

LIMA-LAD Carotid-subclavian

bypass


4/15

9/12/20

CY: 67yo female

Presents complaining of left arm

weakness/pain Reports severe weakness and pain of

9/12/2011 19

, ,

effort

Unable to do usual daily activities

Hx. of CABG, hyperlipidemia

60mm Systolic BP gradient left-to-right

9/12/2011 21

Preferred option

likely carotid-

brachial bypass

Long-segment

Crosses thoracic

outlet

Non-diseased

carotid

67yo female S/P mastectomy/radiation for

CA

Chronic lymphedema

New gangrene of the thumb

Long-segment axillary/brachial stenting

performed by radiology

Initial improvement with some wound

healing, but occluded at 3mo.


5/15

9/12/20

Thoracic Outlet Syndrome

Distinct resentation from atherosclerotic disease

in virtually every case

Present in the young, active, non-atherosclerotic

population

29yo female with right arm

swelling

Reports sudden onset of severe, painful and

disabling right arm swelling 4 months prior

Presented to student health and was sent home

with ASA and a referral to PT

Painful symptoms resolved and severe swelling

improved, but has persistent mild swelling

Referral to Vascular 4 months later

Pt. is a former competitive swimmer

Physical exam:

Right arm slightly larger than the left

Few prominent venous collaterals about

Strong radial pulse

CXR

Venogram

Arm in adduction Arm in abduction

Anatomy of the Thoracic

Outlet


6/15

9/12/20

Thoracic Outlet Syndrome Thoracic Outlet Syndrome

Thoracic Outlet SyndromeEpidemiology of Thoracic Outlet

Syndrome

develops during the 3rd or 4th decade

classically said to occur in thin, athletic

females and males with pronounced upper

body development (weightlifters)

Female/male ratio as high as 4:1

Types of TOS

95

70

80

90

100

1 3

0

10

20

30

40

50

60

%

Arterial

Venous

Neurogenic

Diagnosis of Thoracic Outlet

SyndromeCXR


7/15

9/12/20


SyndromeCXR Bony Anomalies

Diagnosis of Thoracic OutletPhysical exam

EAST Test or "Hands-up" Test

The patient brings their arms up as shown with

elbows slightly behind the head. The patient then

opens and closes their hands slowly for 3 minutes.

A positive test is indicated by pain, heaviness or

profound arm weakness or numbness and tingling

of the hand.


Adson or Scal ene Maneuver

The examiner locates the radial pulse. The patient

rotates their head toward the tested arm and lets

the head tilt backwards (extends the neck) while

the examiner extends the arm. A positive test is

Physical exam

indicated by a disappearance of the pulse.

Caveat: Change in pulse amplitude in up to 53% of

normal volunteers


8/15

9/12/20

Arterial TOS

Upper extremity

embolization

Pulsatilesupraclavicular

mass

Sudden onset arm

ischemia

Arterial TOS: Uniformly

straightforward with good resultsArter ial i njuri es in the t hor acic

outlet syndromeJoseph R. Durham, MD, James S. T. Yao, MD, PhD, William H. Pearce, MD ,

Gordon M. Nuber, MD, and Walter J. McCarthy III, MD, Chicago, Ill.

22 patients with arterial TOS and subclavian artery injury

73% with a cervical rib

50% with distal embolization

50 % requiring arterial reconstruction

All underwent thoracic outlet decompression

100% patency at F/U

J Vasc Surg. 1995 Jan;21(1):57-69

Arterial TOS: Axillary variant

Compression of the axillary artery by the humoral head with

repetitive stress in certain athletes (mainly pitchers)

Art eria l in ju ries in t he th oracic

outlet syndromeJoseph R. Durham, MD, James S. T. Yao, MD, PhD, William H. Pearce, MD,

Gordon M. Nuber, MD, and Walter J. McCarthy III, MD, Chicago, Ill.

12 patients with axillary artery involvement

thrombosis (1), aneurysm (2),

symptomatic extrinsic compression only (9).

Five patients treated without a surgical procedure;

three underwent decompression procedures only,

four had direct arterial repair.

All axillary artery reconstructions were patent at last follow-upexamination (mean 31 months).

J Vasc Surg. 1995 Jan;21(1):57-69


9/15

9/12/20

Venous TOS

Upper Extremity Swelling

Differential diagnosis

Lymphedema

Superior vena cava syndrome

Axillo-subclavian vein thrombosis

Pacer wires

lli i lli i

Paget Schroetter syndrome

Axillo-subclavian vein

thrombosis

Effected arm

swellin

Standard approach to Paget-

Schroetter

Venogram in adduction and abduction

If symptoms are chronic and subclavian vein

occluded-no therapy

crossed, begin lysis

Thrombolysis until subclavian vein is clear

First rib resection via axillary or supraclavicular approach

May be immediate or delayed

Venous Thoracic Outlet Syndrome

Pre-thrombolysis

Subclavian vein

thrombosis


10/15

9/12/20

Venous Thoracic Outlet Syndrome

Post thrombolysis

Subclavian vein

Patent w/ stenosis

Approach to venous thoracic outlet:

significant variance

The aggressive

First Rib Resection and Scalenectomy forChronically Occluded Subclavian Veins:

What Does It Really Do?Ricardo de Leon, David C. Chang, Christopher Busse,

Four patients with chronic, symptomatic

subclavian vein occlusion

All re-opened after first rib resection

Average of 7 months to recanalization

Diana Call,

and Julie Ann Freischlag, Baltimore, Maryland

The even more aggressive

Comprehensive surgical management of the

competitive athlete with effort thrombosis of

the subclavian vein (Paget-Schroetter

syndrome)

Spencer J. Melby, MD, Suresh Vedantham, MD, Vamsidhar R.

Narra, MD, George A. Paletta Jr, MD, Lynnette Khoo-Summers,

MSPT, Matt Driskill, MSPT,

and Robert W. Thompson, MD, St Louis and Chesterfield, Mo

32 competitive athletes with effort thrombosis

81% underwent thrombolysis and 100%

underwent first rib excision and operative

venolysis

44% underwent venous reconstruction via patch

angioplasty or saphenous panel grafts

AVFs created in patients with reconstruction

Three patients with post-op thrombosis

All with return to athletics

22 pts treated between June 1996 and June 1999

i i i

Approach to venous thoracic outlet:

The not-so aggressive

Surgical intervention is not required

for all patients with subclavian vein

Thrombosis

W. Anthony Lee, MD, Bradley B. Hill, MD, E. John Harris, Jr, MD,

Charles P. Semba, MD, and Cornelius Olcott IV, MD , Stanford, Calif

9 of 22 patients (41%) did not require surgery,

Recurrent thrombosis developed in only one patient during anticoagulation.

11 of 13 patients (85%) treated with surgery and 8/9 patients (89%) treated without

surgery sustained durable relief of their symptoms and a return to their baseline

level of physical activity.

All patients who underwent surgery maintained their venous patency on follow-up

duplex

Conclusions

Not all patients with primary axillary-subclavian vein thrombosis require surgicalintervention.

No chronic anticoagulationJ Vasc Surg. 2000 Jul;32(1):57-67

i i i l i i i i i -

Combined rib resection and

PTA

Combination treatment of venous thoracic outlet

syndrome: Open surgical decompression and

intraoperative angioplasty

Darren B. Schneider, MD, Paul J. Dimuzio, MD,c Niels D. Martin, MD, Roy L. Gordon, MD,

Mark W. Wilson, MD, Jeanne M. Laberge, MD, Robert K. Kerlan, MD, Charles M. Eichler, MD,and Louis M. Messina, MD, San Francisco, Calif; and Philadelphia, Pa

i i i l i , i i i i -

venogram/PTA

Intraoperative venography enabled identification of residual subclavian vein

stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100%

technical success.

Postoperative duplex scans documented subclavian vein patency in 23

patients (92%).

recurrent thrombosis in 2 patients (8%),

One-year primary and secondary patency rates were 92% and 96%

Schneider DB, et al (UCSF) J Vasc Surg. 2004 Oct;40(4):599-603

Role of subclavian vein stents s/p 1st rib

resection

Long-term results in patients treated with

thrombolysis, thoracic inlet decompression, and

subclavian vein stenting for Paget-Schroetter

syndromePaul B. Kreienberg, MD, Benjamin B. Chang, MD, R. Clement Darling III, MD, Sean P. Roddy, MD,

Philip S. K. Paty, MD, William E. Lloyd, MD, David Cohen, MD, Brian Stainken, MD, and Dhiraj M.Shah, MD, Albany, NY

23 patients with thrombolysis, first rib resection, and immediate venography

14 pts w/ residual vein stenosis (>50%) after PTA underwent sub clavian vein

stenting

All PTA are paten t, wi th a mean fo llo w-up o f 4 years (r ange, 2-6 years).

9 of 14 stents patent, with a mean fol low-up of 3.5 years

ConclusionPatients with short-segment venous strictures after successful lysis and thoracic

outlet decompression may safely be tr eated with subclavian venous stents and can

expect long-term patency


11/15


12/15


13/15

9/12/20

Conservative criteria for surgical

intervention

Classic Physical exam findings Failed 3-6 month trial of Physical therapy

euro ogy ru es ou o er causes

cervical radiculopathy

Scalene block relieves symptoms

Not on Workmans comp.

Operative Options

First rib resection Scalenectomy

Cervical rib resection

Brachial plexus neurolysis

Recurrent TOS

Supraclavicular approach

Anterior/middle scalene resection if not

previously done

rst r resect on not prev ous y one

Complete neurolysis

Results of Surgery: highly

variableThe Good

Reported In-Hospital Complications

following Rib Resections for Neurogenic

Thoracic Outlet Syndrome

David C Chan AnneO Lidor SusannaL Matsen and JulieA Freischla

National Inpatient sample: 2016 TOS

operations

Average length of stay 2.51 days

.60% rate of brachial plexus injury

1.74% rate of vascular injury

Concludes that TOS surgery is safe

. , . , . , . ,

Baltimore,Maryland

Ann Vasc S urg. 2007 Sep t;21(5)564-70 .

Clinical research study

Surgical intervention for thoracic outlet syndrome

improves patient's quality of life Presented at the 2008

Vascular Annual Meeting, San Diego, Calif, Jun 5-8,

2008.

David C. Chang PhD, MPH, MBA, Lisa A. Rotellini-Coltvet MA, MMS, PA-C, Debraj Mukherjee MD, MPH, Ricardo

De Leon MD and Julie A. Freischlag MD

70 patients operated on for neurogenic or venous TOS

ll l i ili l ll comple e - an isa ili y arm , an , s oul er

surveys pre and post-op

Significant improvement in scores at 24 months post-op

JVS Volume 49, Issue 3, March 2009, Pages

630-637

Results of SurgeryThe bad

i i i

Long-term functional outcome of neurogenic

thoracic outlet syndrome in surgically and

conservatively treated patientsGregory J. Landry, MD, Gregory L. Moneta, MD, Lloyd M. Taylor, Jr, MD, James M. Edwards,

MD,

and John M. Porter, MD, Portland, Ore

79 patients with neurogenic TOS

Divided into operative and non-operative groups

34% of operative groups with significant symptomatic

improvement32% of non-operative group with improvement

60% of operative group returned to work, 78% of non-operative

group

Concluded first rib resection does not improve functional

outcome

J Vasc Surg. 2001 Feb;33(2):312-7


14/15

9/12/20

TOS and Workmans Comp: The

Really Bad

Outcome of surgery for thoracic outlet

syndrome in Washington state

workers compensationGary M. Franklin, MD; Deborah Fulton-Kehoe, MPH; Cynthia Bradley, MS, MPH;

and Terri Smith-Weller, MN

158 Pts. Operated for TOS

60% still disabled at one year

70% with significant limitations

Significantly less lost work days inconservatively managed patients

30% with an acute complication

17% with a new neurologic complaintafter surgery

First Rib Resection Operative

Approaches Transaxillary

Cosmetically appealing

Avoids venous collaterals

More difficult to do neurolysis or arterial reconstruction

Better exposure of cervical rib and brachial plexus

Familiar dissection

Difficult to do arterial repair

Difficult to fully release the most medial compression of the vein

Paraclavicular Maximum exposure for arterial reconstruction/rib resection

Cosmetically less appealing

Supraclavicular Approach Supraclavicular Approach

The platysma is opened and the

external jugular vein isolated and

divided

The clavicular head of the sternocleidomastoid muscle is

divided and the underlying scalene fat pad dissected from

lateral to medial

Supraclavicular approach Supraclavicular Approach

The anterior scalene muscle was exposed and

the medial cord of the brachial plexus was

encircled with a vessel loop and gently retracted

laterally.

The subclavian artery was encircled with a vessel loop

and retracted medially. The anterior scalene muscle was

carefully divided, exposing the first rib.


15/15

9/12/20

Supraclavicular Approach

The first rib is cleared of intercostal muscular

attachments and resected with small bites of a

double action rongeur.

The cut end of the first rib is visible between the

subclavianartery and brachial plexus

Transaxillary Approach

Anatomy of the Thoracic Outlet Anatomy of the Thoracic Outlet

Thoracic Outlet Syndrome Summary Subclavian/Axillary Atherosclerosis

Rarely Symptomatic

May be due to flow limitation or atheroembolic

Usually treated with angioplasty/stent or extranatomic bypass

Occasionally direct aortic-based reconstruction

Thoracic Outlet Presentation

i i i i l i ree is inc presen a ionsar erial, venous, neurogenic

Arterial due to bony abnormalityMay be embolic or flow-limiting

Venous presenting as effort thrombosis

Neurogenic with pain paresthesias in unpredictable upper ext. neck

distribution

Thoracic Outlet Treatment

Arterial: first/cervical rib resection and often arterial interposition

graft

Venous: thrombolysis, first rib resction, venogram with angioplasty

Neurogenic: First rib resection with scalenectomy

okluzija vene gornjih ekstremiteta

Documents