Outcomes following operative management of thoracic outlet syndrome in the pediatric patients

Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.

Open surgery for iliofemoral deep vein thrombosis with temporary arteriovenous fistula remains valuable

Objective We assessed outcomes of open surgical venous thrombectomy with temporary arteriovenous fistula, and the procedure’s effect on health-related quality of life. Method We retrospectively analyzed 48 (26 at long-term) patient medical records. Mortality rates, patency, and risk of post-thrombotic syndrome were analyzed using Kaplan–Meier estimation. The association between risk factors/coagulation disorders and patency/post-thrombotic syndrome along with patient health-related quality of life at long-term was analyzed employing various statistical methods. Results Patient one-year survival rate was 93 ± 4% and primary one-year patency rate was 89 ± 5% (secondary one-year patency rate 97 ± 3%). Freedom from post-thrombotic syndrome after eight years was 80 ± 12% (post-thrombotic syndrome rate 20 ± 12%). Health-related quality of life was impaired vs. normative data in the physical and social subscales, and in the mental component score ( p < .05). Conclusions Open surgical venous thrombectomy appears safe compared with literature-reported outcomes in similar patients using alternative approaches. Iliofemoral deep vein thrombosis impairs physical, social, and mental health-related quality of life.

Late Results after Thrombectomy for Ilio-Femoral Venous Thrombosis

Sixty-three of 68 patients who underwent thrombectomy with a temporary arteriovenous fistula for ilio-femoral venous thrombosis were followed-up after a mean time of 66 months (range 15–130). Fifty-four were women with a mean age of 29 years (range 13–66). A primary successful operation was performed in 54 patients (86%); at 16 months 34 (54%) were judged to have a patent ilac vein. At long-term follow-up 23 patients had no symptoms, 17 had leg swelling, venous claudication and/or present or previous ulcer while 23 had leg swelling only. Fourteen (22%) had noticed a decreased capacity to perform their job and 21 (33%) had to compensate daily for the discomfort of the diseased leg. Recurrent thrombotic disease occurred in eight patients and did not seem to be associated with symptoms at follow-up. The results of the operated patients seem to be favourable compared to other reports of conservative treatment, especially for fertile women and with a reduced risk of future venous insufficiency. In young patients with a long life expectancy this is particularly important.

Results of Femoro-Femoral Vein Bypass Grafting with Temporary Arteriovenous Fistula for Femoro-Iliac Venous Thrombosis: Differences between Operations in the Acute and Chronic Phases

Femoro-femoral vein bypass operation using a synthetic vascular graft with simultaneous construction of a temporary arteriovenous fistula (A-V f.) was performed in eight patients with acute femoro-iliac venous thrombosis after successful femoral thrombectomy but unsuccessful iliac thrombectomy; this operation was also performed in one patient with subacute thrombosis of the iliac vein and three patients with femoro-iliac post-phlebitic syndrome. Of the first nine patients who underwent the operation in the acute or subacute phase of the disease, the synthetic vascular grafts remained patent after closure of the A-V f. in six (66.7%), and no recurrence of symptoms was observed in any of the nine, including those in whom the graft was occluded. However, the graft remained patent in only one (33.3%) of the three patients who underwent the operation in the chronic phase and no improvement in symptoms was observed in the patients with occluded grafts. These differences in the results of bypass grafting are considered to be due to differences in the development of pelvic venous collaterals. The indications for this operation should be evaluated after close examination of the state of collateral vasculature.

Long-Term Results of Thrombectomy with Temporary Arteriovenous Fistula for Ileofemoral Venous Thrombosis

Nineteen patients with acute ileofemoral venous thrombosis were subjected to thrombectomy with the addition of a temporary a-v fistula and anticoagulant treatment. At follow-up 3 years after surgery isotope phlebography disclosed more-or-less patent ileofemoral segments in 16 patients. The venous outflow capacity as estimated from venous emptying curves was normal in all but three totally occluded limbs, indicating an adequate collateral compensation. Foot volumetry demonstrated signs of venous valvular insufficiency, mainly in legs with a distal extension of the initial thrombosis; these patients complained of symptoms of post-thrombotic syndrome, which emphasizes the importance of early operation.