Safety of Transaxillary Approach in Thoracic Outlet Syndrome Surgery in 484 Cases

Thoracic outlet syndrome (TOS) is a group of symptoms caused by compression of neurovascular structures serving the upper extremity. In patients with severe disease, disability symptoms, and failed physical therapy, surgical treatment is recommended for decompression. The aim of our study was to report the safety of transaxillary (TA) approach in TOS surgery.

We retrospectively collected demographic and clinical data for all patients that underwent surgery for TOS from January 1^, 2012, to December 31, 2021, in our center.

Over 10 years, 346 patients underwent surgery for TOS in 484 upper limbs. The mean age was 37.9 ± 10.6 years, with 242 female (69.9%). Vascular complications were reported in 141 (29.1%) limbs, with 5 (1%) acute limb ischemia, 104 (21.4%) ectasia of the subclavian artery, and 32 (6.6%) venous thrombosis. Positive findings at electromyography were reported in 185 (38.2%) limbs. TA approach allowed first rib removal in 466 cases (98.5%) associated with pectoralis minor section in 201 (43%) cases. Pectoralis minor section alone was performed in 7 (1.4%) cases. Twenty-four (82.7%) cervical ribs were removed, and 1 redo surgery was performed through the TA approach. At 6-weeks, neurological injuries were reported in 2 (0.5%) cases, with 1 C8-T1 injury and 1 axillary nerve injury. No phrenic nerve or long thoracic nerve or dorsal scapular nerve injuries were reported. Hemothorax requiring reintervention were reported in 13 (2.7%) cases, and pneumothorax requiring chest tube in 21 (4.3%). Medial brachial nerve palsy was reported in 57 (11.7%) cases.

The TA approach in TOS surgery allows complete first rib resection with access to the posterior part of the first rib. We confirm its safety especially regarding neurological complications. Diagnostic criterions and functional results need more evaluations, but these further results, which we are willing to report, are conditioned to the safety of our practice.