Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3727_Библиотеки_им_академика_М_И_Перельмана

Venous thoracic outlet syndrome (vTOS) is a clinical syn­drome caused by dynamic compression of the subclavian vein (SV) which can progress to deep venous thrombosis (DVT). It comprises approximately 2%–3% of all cases of TOS, which collectively include arterial, venous, or neuro­genic TOS [1].

fascia until the edge of the chest wall is reached. In cases of vTOS, there can be signicantly large collaterals running through the axillary space. Typically, these can be preserved but may require ligation if their presence will hinder full visualization of deeper structures. Once dissection is carried down the chest wall, blunt dissection can often be carried up to the level of the rst rib. The subclavian vein can usu­ally be identied and followed to where it runs near the rst rib. The visualization is aided by narrow long retractors, but care should be taken to avoid placing this directly on the brachial plexus. At this point, the subclavian vein, ante­rior scalene muscle, and subclavian artery should be clearly visualized. The phrenic nerve will course lateral to medial and is often above the cephalad portion of the dissection, though care should be taken to identify any abnormal courses within the surgical eld. ACobb elevator is then used to separate the intercostal muscles from the anterior border of the rst rib. Once this is completed both medi­ally and laterally, the parietal pleural can also be bluntly separated from the underside of the rib, often with the backside of the Cobb elevator. Aright angle is then placed around the anterior scalene to isolate it, ensuring there are no branches of the subclavian artery, vein, or phrenic nerve within the anticipated area of dividing. The anterior scalene is then sharply divided. The Cobb or periosteal elevator can be used to divide the middle scalene off the rib, taking care not to injure the long thoracic nerve, which may be a sin­gle nerve or three separate nerves at this point. An angled long-handled rib cutter is then inserted, and the rst rib is divided rst anteriorly medial to the subclavian artery. The subclavius muscle or costoclavicular ligament may require division to allow for medial placement of the rib cutter. Once completed, the bone can be divided posteriorly with the rib cutter. Arongeur can then be used to ensure there is a smooth bone edge without impingement on the lower nerve root of the brachial plexus. Afocused venolysis of the subclavian vein can be performed with Metzenbaum scis­sors to ensure any remaining bands or compressive scars are removed to allow for full venous expansion. Once all dissection is completed and the rib is removed, the wound is lled with normal saline and the anesthesiologists are asked to perform a Valsalva maneuver to evaluate for violation of the pleura. This may be apparent if a large volume of the instilled saline is lost in the wound or if there are air bub­bles with Valsalva. If a violation is noticed, there are several mechanisms for treating, which involve placing a suction catheter through the pleural defect and evacuating the uid in the chest. Postoperatively, the timeline for restarting anti­coagulation is not well studied. In our practice, patients are maintained on aspirin for 5 days and then restart their oral anticoagulation on postoperative day 6.

Post-thrombotic syndrome (PTS) has been dened in stud­ies as persistent signicant swelling with pitting edema and is a known complication of UEDVT. In 2018, Thiyagara­jah etal. conducted a systematic review and meta-analysis regarding PTS with UEDVT and identied 22 studies with a total of 944 patients. The pooled proportion of PTS using a random effects model was 19.4% (95% CI 11.3–27.6). They then analyzed the recurrence of UEDVT in 37 studies with a total of 2552 patients and found the overall propor­tion of recurrent DVT was 7.5% (95% CI 4.1–10.9), with a higher proportion in secondary vs primary UEDVT (15.9 vs 6.4%).

The study by Korkeila et al. found that pacemaker implantation induced a transient hypercoagulable state, but the patient’s degree of hypercoagulability did not pre­dict subsequent venous thromboembolism. The authors concluded that thrombosis formation with pacemaker leads was likely to involve the three components of the Virchow triad: stasis, hypercoagulability, and endothelial damage, which has been echoed by other studies.