Changing Strategies to Treat Venous Thrombotic Occlusions of the Upper and Lower Extremities Secondary to Compressive Phenomena
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Abstract:
We reviewed our strategies during the last decade for deep vein thrombosis (DVT) of the upper extremity due to thoracic outlet syndrome (TOS) andthe lower extremity.Between 1998 and 2011, we treated 31 patients with 18 subclavian DVTs and 13 iliac DVTs. Management included catheter-directed thrombolysis compared to mechanical thrombolysis (MT; post 2006). Prior to 2006, patients with TOS were treated with total excision of the first rib compared to excision of the anterior half of the rib. Patients were followed up with serial duplex ultrasounds.There was no major morbidity and no mortality in these 31 patients. Three patients developed recurrent DVT but maintained patency after further treatment.Use of MT has led to shorter treatment duration and length of hospital stay. Limiting first rib resection to the anterior half of the rib shortened operative time. Patients requiring stents had excellent long-term patency rates.Keywords:
Subclavian vein
The possibility to study axial anomalies directly on a skeletal individual is not very frequent. One well preserved skeletal individual from an Italian site dating to the late antique period (5th -4th cen-turies CE) was studied. This individual shows some interesting skeletal changes in the vertebrae and ribs. A supernumerary rib was found. It is a cervical rib connected to the 1st thoracic rib, pre-sumably with a fibrous bundle. The presence of cervical ribs can produce neurovascular compres-sion of the brachial plexus and subclavian vessels. Because of this, it is often a cause of thoracic out-let syndrome (TOS). In our case the presence of a cervical rib articulated with the first thoracic rib through a probable fibrous band could have re-stricted the space where the brachial plexus and subclavian vessels pass through, creating a state of neurovascular compression, similar
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Thoracic outlet syndrome (TOS) describes compression of the neurovascular bundle of the brachial plexus, subclavian artery, and/or subclavian vein as they leave the thoracic outlet. A 40-year-old female with history of thoracic outlet syndrome status-post left first rib resection presented in 2021 with symptoms of recurrent TOS due to the presence of a residual first rib. A transaxillary approach was performed and a partial second rib resection was required to remove the residual first rib. At 4½-month follow-up, there was improvement in all symptoms.
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THE THORACIC outlet syndrome is a well-known clinical entity. Reports of neurovascular compression by a cervical rib, the scalenus anticus muscle, deformity of the clavicle, and other anatomical variations have appeared frequently. Although anomalous first ribs also distort the thoracic outlet, they have only rarely appeared in the literature as a cause of the syndrome. Two cases of thoracic outlet syndrome associated with anomalous first ribs are presented.
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A 32-year-old white man was admitted to the hospital because of pain in the left shoulder and hand. He stated that when he was 20 years old he became aware of a painful mass in the left supraclavicular space. This mass was hard and tender, and pain in the region of the mass was associated with pain in the left axilla and along the medial aspect of his left arm. The pain descended down his left forearmCervical rib
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Paget Schroetter syndrome (PSS) is effort-induced thrombosis of the axillary and subclavian veins associated with compression of the subclavian vein at the thoracic outlet. It is the venous variant of thoracic outlet syndrome (TOS), the syndrome of symptoms associated with compression of the subclavian vein, subclavian artery, or brachial plexus as they pass through the thoracic outlet. The description of this entity dates back to 1875 when Sir James Paget reported a case of spontaneous thrombosis of the subclavian vein in a patient. In 1884, von Schroetter hypothesized that the condition was a consequence of injury to the vein from repetitive musculoskeletal motion.
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Cervical rib is a well-documented congenital anomaly, and thoracic outlet syndrome (TOS) with vascular compression is extremely rare in childhood. The subclavian artery, subclavian vein, brachial plexus, or a combination of these can be affected in this syndrome. We present a case of TOS in an eight-year-old boy and describe the rare finding of subclavian artery compression with post-stenotic dilatation and severe brachial plexus compression symptoms. The patient underwent right transaxillary resection of the first thoracic and cervical rib. The presentation is unique and may be elusive.
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Background: Neurogenic thoracic outlet syndrome typically presents with paresthesia, pain, and impaired strength in the neck, shoulder, and arm, and is typically a diagnosis of exclusion. This condition is caused by compression of the brachial plexus, typically by a bony or soft tissue anomaly present congenitally and influenced by repetitive motion or significant trauma. Treatment typically involves removal of the first rib and anterior scalene to decompress the thoracic outlet and relieve stress to the brachial plexus if the patient has failed conservative treatment with physical therapy and lifestyle modifications. Case Presentation: We present a case of neurogenic thoracic outlet syndrome with arterial compression treated surgically via a transaxillary first rib and cervical rib resection in a patient with bilateral cervical ribs and osteochondromas of the ribs.
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Reported here is a 13-year-old girl suffering from pain in her right lower neck region and the shoulder for the preceding 2–3 years. She was diagnosed to have right thoracic outlet syndrome due to bifid ribs–caused by the bony fusion of the variant cervical rib. She was operated via supraclavicular approach, whereby the variant cervical rib and the fibrous bands were excised. She was found to be quite improved 1 month after surgery. Thoracic outlet syndrome, a rare disease of childhood, is discussed in the light of the relevant literature. Clin. Anat. 19:558–560, 2006. © 2006 Wiley-Liss, Inc.
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