Thirty-year experience of transaxillary resection of first rib for thoracic outlet syndrome

Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years.

A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates.

One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%).

In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.