We have dedicated a number of recent posts to the discussion of thoracic outlets syndrome (TOS), a condition which causes compression of the blood vessels and nerves at the top of the chest. Drs. Sam Ahn and Robert Feldtman of DFW Vascular, along with other colleagues, study this condition and recently found that compression (stenosis) of the internal jugular vein is found in patients with TOS.
This finding represents a new concept in the diagnosis of this often debilitating condition. Furthermore, the authors reported that using a balloon on the tip of a catheter to expand the compression or blockage in the jugular and/or subclavian veins can relieve symptoms of TOS. This new concept will be presented to other surgeons at the Fall semi-annual meeting of The Texas Surgical Society to be held this September in Houston (http://txsurgicalsociety.com/UpcomingMeeting.aspx).
Below is the abstract of the scientific paper to be presented at the meeting.
TITLE: Percutaneous Transluminal Angioplasty as Therapy for Thoracic Outlet Symptoms
AUTHORS: Ahn, Samuel S; Chen, Julia F; Miller, Travis J.; Chen, Sheena W.; Feldtman, Robert; Hwang, William
OBJECTIVES: Traditionally, thoracic outlet syndrome (TOS) has been associated with axillo-subclavian vein stenosis without any mention of the internal jugular (IJ) vein. However, we recently reported a high prevalence of IJ stenosis in 109 patients with TOS in a limited study. To further understand the clinical significance of this finding, we analyzed a larger cohort of patients and their subsequent follow-up.
METHODS: We retrospectively analyzed 237 consecutive unique patients referred to our practice with thoracic outlet syndrome. From April ’08 to Dec ’12, all patients underwent diagnostic brachiocephalic venograms. Average age was 49.9 years (r:17 to 81), with 71.8% females and 28.2% male. We looked at the right and left internal jugular veins and the right and left subclavian veins. Stenoses were classified into high (>66%), medium (33%-66%),and low (<33%). We also looked for presence of collaterals around the obstructions. Venogram findings were independently confirmed by four investigators. For the purposes of this analysis, high stenosis was considered significant. Medium and low stenoses were considered significant only if there were visible collaterals. Of this group, we then looked at all patients who received intervention via PTA at the stenosed IJ sites. Patients were categorized into Groups I or II. Group I: patients who received no immediate relief of symptoms after PTA; Group II: patients who did receive immediate relief of symptoms after PTA. Group II was further broken down into subgroups IIA, IIB, and IIC. Group IIA: those who required additional surgical intervention due to symptom recurrence; Group IIB: those who report sustained relief; Group IIC: those who were lost to follow-up.
RESULTS: Left internal jugular vein stenosis, left subclavian vein stenosis, right internal jugular vein stenosis, and right subclavian vein stenosis was seen in 67.5%, 57.6%, 62.7%, and 61.6% of patients, respectively. Internal jugular vein stenosis was not present in 18.1% of patients, present unilaterally in 33.3% of patients, and present bilaterally in 48.5% of patients. Subclavian vein stenosis was not present in 24.1% of patients, present unilaterally in 32.5% of patients, and present bilaterally in 43.5% of patients. Significant collaterals were present in 26.80% of high stenosis, 21.5% of medium and 12.8% of low. Of 237 patients, 67.7% (n=147) received PTA intervention. Of those who received intervention, 28.6% (n=42) were in Group I, 67.4% (n=99) were in Group II, and 4% (n=6) did not have available data. Of those in Group II, the breakdown was as follows: IIA (35%, n=34) with a median of less than 7 days (r: 2-210) of relief; IIB (31%, n=31) with 120 days (r: 5 to 406) of follow-up; IIIC (31%, n=31) with 93.5% (n=29) reporting sustained relief at 7-day follow-up and median follow-up of 7 days (avg: 25, r: 6-182).
CONCLUSIONS: Internal jugular vein stenosis is common in patients with thoracic outlet symptoms and percutaneous treatment provides benefit to some patients. These findings could fundamentally change the diagnosis and treatment of thoracic outlet syndrome. Further studies are warranted.