Watch as Vascular Specialist, Animesh Rathore, M.D., performs thoracic outlet decompression surgery on a patient that presented with a left upper extremity deep vein thrombosis. Dr. Rathore highlights the surgical steps necessary to successfully remove the compression on the left subclavian vein.
Hello, my name is uh Doctor Anchor, uh one of the vascular surgeons with Sara. I practice at the Norfolk General Hospital and uh I practice a full spectrum of vascular surgery. Today, we are going to talk about what's called a thoracic outlet syndrome. It's a complex syndrome affecting the nerves, veins and the artery in that order of frequency where these structures get compressed in the thoracic outlet. Uh We will talk about the nuances of this and we will discuss a case of a patient who I took care of about a couple of months ago and we'll talk briefly about the surgical steps for the same. So let's review the anatomy for Thoracic Outlet Syndrome. In Thoracic outlet syndrome, we can see the compression at three specific points most commonly at the middle circle where the veins or the nerves or the artery can get compressed by the first rib clavicle and the muscles around it. The other common area is the pectoralis minor, which is the lower left circle. And rarely, we will see the compression of structures between the anterior and the middle scaling muscles. This diagram shows the schematic representation of thoracic outlet compression in the more common place where you can see the compression of the subclavian vein artery or the nerves from bacal plexus between the clavicle, first rib and the scaling muscles. Our patient here presented with a left upper extremity, deep vein thrombosis from the thoracic outlet, compression of the left sole vein. Initially, this patient was managed with anticoagulation and thrombolysis to clean his vein out, followed by a planned surgery for decompression of thoracic outlets intraoperatively. We do the surgery where we marked the sternal notch as well as the clavicle. Our incision is planned about a finger breadth below the level of the clavicle and the patient is under general anesthesia. So we have made our incision here through the skin and the subcutaneous tissue. We are dissecting along the pectoralis major muscle and underneath we find the subclavian vein. As you can see, there is significant scarring around the subclavian vein and it looks white more than blue, which is also representative of chronic scarring. We are passing a vessel loop around the subclavian vein and checking for the space at this point as we move along, we have to be careful about identifying the long thoracic nerve as well as the muscular structure as we move along. This case. We are also feeling for the first rib which is directly underneath the vein and subsequently, we will retract this vein and start with freeing up some of the sub clavius muscle which goes from the clavicle. And here we are, after freeing up the muscles, we are dividing the first rib using the wrong or to make sure we get enough clearance of the first rib. And there is no residual compression. We check several times to make sure there are no sharp bony edges that would potentially compress the vein later on. And once we are happy with that, we make sure the vein lies without any tension or extrinsic compression. You can also see the lung expanding underneath without any rent in the pleural space or causing any pneumothorax. After we are done, we inject local anesthesia to help with post operative pain. And uh we proceed with closure of the skin which is done in multiple layers. We also perform a valsalva maneuver to make sure there was no rent in the pleura. The deep layers are then closed with the absorbable sutures in multiple layers. And that is followed by the closure of the skin. This patient did very well stayed in the hospital overnight. This is a specimen of the first rib that was removed. Now, there is an extra amount of rib that was taken in piecemeal fashion. A couple of weeks later. This is how the incision looks. This patient did very well and his arm swelling resolved completely after the surgery.
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