Surgeon Shares Tips for Treatment of Thoracic Outlet Syndrome

In the SVS @ STS session, Michael P. Fischbein, MD, PhD, Stanford, Calif., spoke about conservative management of acute type B dissections.

Cardiothoracic and vascular surgeons came together to share their insights on several of their overlapping interests during the Monday afternoon SVS @ STS session.

“STS and the Society for Vascular Surgery have held collaborative programs at each other’s annual meetings for the last 4 years. The collaborations bring state-of-the-art, evidence-based practice together from two different worlds,” said co-moderator A. Michael Borkon, MD, Co-Director of the Mid-America Heart Institute and Chair of the Department of Cardiovascular Surgery at Saint Luke’s Health System in Kansas City, Mo.

Presenters from both societies shared their perspectives on three areas: conservative management and stent grafting of acute type B dissections, open treatment and endovascular repair of thoracic aortic aneurysms, and cardiothoracic and vascular surgery approaches to arterial/venous thoracic outlet syndrome.

John A. Kern, MD said that treating thoracic outlet syndrome is so rewarding that he has continued caring for these challenging patients for nearly 20 years.

“The more experience you gain, the better you get at figuring out who is going to benefit from surgery and who is not,” said Dr. Kern, Professor of Surgery, Chief of the Division of Cardiothoracic Surgery, and Surgical Director of the Cardiac Transplant and Circulatory Device Program at the University of Virginia Health System in Charlottesville.

For Dr. Kern, the days of seeing patients living with arterial thoracic outlet resulting in subclavian artery aneurysms and distal embolization are for the most part gone, as these patients are now being referred earlier. He finds patients with venous thoracic outlet to be extraordinarily challenging because they tend to be young athletes who are pitchers, swimmers, and tennis players intent on continuing their athletic careers.

“Sometimes this diagnosis can be missed, but it should not be; if it is, the results can be devastating,” he said. “The treatment for venous thoracic outlet is really quite straightforward.

“I lyse the clot and operate sooner rather than later. In order to decompress and reconstruct the vein, an infraclavicular incision is best. This allows you to remove the subclavius muscle and costoclavicular ligament, as well as the medial aspect of the first rib, and totally mobilize the subclavian vein. You need to free up the entire vein as it goes under the clavicle, under the manubrium, and into the mediastinum. Sometimes these patients may need extensive reconstruction, necessitating a partial upper sternotomy. There are a lot of different ways to reconstruct the vein after it’s decompressed. These details learned along the way help enhance the chances of a good outcome.”

Intended to be thought provoking and give attendees the opportunity to learn from members of both specialties, the session also featured Julie A. Freischlag, MD, Sacramento, Calif., who shared her approach as a vascular surgeon to arterial/venous thoracic outlet syndrome.