Transaxillary approach for thoracic outlet syndrome: results of surgery

Thoracic outlet syndrome (TOS) is one of the most complicated diseases in thoracic surgery with regard to both diagnosis and treatment. Surgical removal of the first rib and cervical rib, if present, has been suggested as the treatment of choice in patients who do not benefit from physiotherapy. In this retrospective study, our surgical experience with TOS and the management of surgical complications are presented.

A total of 109 cases with the diagnosis of TOS were operated on between January 1995 and April 2010. Ninety-five of the cases were females (87.2 %) and 14 (12.8 %) were males with a mean age of 35.7 (16-58).

A total of 131 operations were performed, of which 21 were bilateral and one was a recurrent operation. The diagnosis was neurogenic TOS in 107 (98.2 %) and vascular TOS in two (1.8 %) patients. All neurogenic TOS operations were performed via the transaxillary route. A posterior thoracoplasty approach was used for recurrent TOS in one case. A total of 23 (21.1 %) cases had a cervical rib. Fibromuscular bands were observed in 68 (62.3 %) cases. The rates for favorable and poor surgical outcome were 125 (95.4 %) and 6 (4.6 %), respectively. The most common complication was apical pneumothorax in 32 (24.6 %) cases, followed by wound infection in four (3 %), lymphatic leak, axillary hematoma and mild brachial plexus traction palsy in one (0.8 %) case. Mortality was not observed.

In our experience the exposure provided by the transaxillary approach is safe and superior to that offered by other approaches as it allows a wide range of surgical applications such as first rib resection, cervical rib resection and resection of fibrotic bands.