Postoperative outcomes in thoracic outlet decompression for acute versus chronic venous thoracic outlet syndrome

Venous thoracic outlet syndrome (VTOS) is a rare disorder that occurs in young athletes and working adults. There are multiple published reports demonstrating excellent outcomes with thoracic outlet (TO) decompression surgery when patients present acutely (within 2 weeks of symptom onset). Our objective was to assess outcomes after decompression surgery in patients with acute, subacute, chronic, and secondary VTOS. Additionally, we sought to identify risk factors for persistence of symptoms following operative decompression.

A retrospective chart review was performed for all patients who underwent operative decompression for VTOS at the University of Pittsburgh Medical Center from 2013 to 2017. We examined baseline characteristics, comorbidities, presenting symptoms, interventions performed, and postoperative clinical outcomes. Patients were characterized as acute, subacute, or chronic based on onset of symptoms and presentation to our surgeons (acute <2 weeks, subacute 2 weeks to 3 months, and chronic >3 months). Our outcomes of interest were return to baseline functional status as defined by resumption of sports activity or occupation and axillosubclavian vein patency.

A total of 51 operative decompressions were performed in 48 patients for VTOS. There were 23 operations (45%) performed on patients who presented acutely, 7 (14%) in the subacute group, and 21 (41%) surgeries in patients with chronic symptoms. Of these 51 operations, 4 (7.8%) were deemed unsuccessful-two surgeries were in the acute group, one in the subacute, and one in the chronic group. The 30-day morbidity after 51 first rib resections included no pneumothoraces, no lymphatic leaks, two surgical site hematomas with associated hemothorax in one patient, two surgical site infections, and only two unplanned returns to the operating room for hematoma evacuation and superficial wound infection washout. In terms of preoperative vein patency, those who presented acutely were more likely to have an occluded axillosubclavian vein (P = .029). The Fisher's exact was 0.540, indicating that the proportion of patients returning to baseline functional status were similar when comparing acute presenters with those who present late. A multivariate Cox proportional hazards model was attempted; however, a small sample size greatly limited the power of the study and prohibited identification of risk factors for surgical failure.

Patients with acute and chronic VTOS resumed their preintervention sports activity or vocation after TO decompression in more than 90% of cases with a low incidence of adverse events. Based on our study results, patients with chronic VTOS benefit as much from TO decompression as those with acute VTOS.