The Evolving Role of Endovascular Therapy in the Management of Arterial Thoracic Outlet Syndrome

ABSTRACT Objective Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery. Methods We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, 1/1986-8/2003 (P-1) versus 9/2003-3/2021 (P-2), and by treatment modality, open versus endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups. Results Out of 2,200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 (31%) aneurysms, 15 (29%) stenoses, and 19 (37%) occlusions. Compared to open aneurysmal repair, endovascular stent graft repairs took less time (241 versus 330 mins, p= 0.09), incurred lower estimated blood loss (103 vs 150 mL, p=0.36), and had a shorter length of stay (2.4 vs 5.0 days, p=0.10). Yet the endovascular group had decreased primary (63% versus 77%, p=0.481), primary assisted (75% versus 85%, p=0.590), and secondary patency rates (88% versus 92%, p=0.719), at mean follow up time of 3.0 years for the endovascular group and 6.9 years for the open group (p=0.324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased post-operatively, 2.9 vs 0.8 (p=0.015) and 42.6 vs 12.6 (p0.004), respectively. Conclusion This study describes the evolving role of endovascular management of ATOS over the last two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single institution. Compared to open repair, stent graft repair of the subclavian artery may be associated with shorter operative times, less blood loss, but decreased patency, without changes in long-term functional outcomes.