Surgical treatment of cervical rib-associated arterial thoracic outlet syndrome

The arterial form of thoracic outlet syndrome is rare and is associated with anatomic anomalies, generally a cervical rib. It has a varied range of manifestations. The aim of this article is to describe two cases with different clinical presentations: microembolization and aneurysm. A cervical rib was present in both cases. Diagnosis was made on the basis of history, physical examination, postural maneuvers, and X-rays. Computed tomography angiography provided the anatomic detail necessary to plan surgery. Surgical treatment was performed via supraclavicular access, successfully, in both cases.

Keywords:
thoracic outlet syndrome; subclavian artery; surgery; decompression; cervical rib; emboli; aneurysm

Authorship

Elpidio Ribeiro da Silva Filho

Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Divisão de Cirurgia Vascular e Endovascular, Ribeirão Preto, SP, Brasil.Universidade de São PauloBrasilRibeirão Preto, SP, BrasilUniversidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Divisão de Cirurgia Vascular e Endovascular, Ribeirão Preto, SP, Brasil.

Marcelo Bellini Dalio

http://orcid.org/0000-0002-2234-6825

Marco Bianco Santarosa

Tércio Ferreira Oliveira

Maurício Serra Ribeiro

Edwaldo Edner Joviliano

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Correspondence Marcelo Bellini Dalio Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Divisão de Cirurgia Vascular e Endovascular Av. Bandeirantes, 3900 CEP 14040-030 - Ribeirão Preto (SP), Brasil Tel.: +55 (16) 3602-2593 E-mail: mbdalio@usp.br

Author information ERSF - 5th year resident, Cirurgia Vascular e Endovascular, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). MBD - Vascular and endovascular surgoen; Primary physician, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). MBS - Vascular surgeon, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). TFO - 4th year resident, Cirurgia Vascular e Endovascular, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). MSR - Associate professor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP). EEJ - Associate professor; Chief of vascular surgery service, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP).

Author contributions Conception and design: ERSF, MBD Analysis and interpretation: ERSF Data collection: ERSF, MBS, TFO Writing the article: ERSF, MBD Critical revision of the article: MBS, MBD, MSR, EEJ Final approval of the article*: ERSF, MBD, MBS, TFO, MSR, EEJ Statistical analysis: N/A. Overall responsibility: ERSF *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

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Figures

Figures (8)

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Figure 1
Image showing the hyperabduction maneuver in the first case. The patient raises her arms at 180º. Pallor is observed and the distal pulses disappears in the affected limb (right).

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Figure 2
Anteroposterior cervical X-ray of the first case showing the cervical rib joined to the first right rib (black arrow). An elongated transverse process of C7 was also observed on the left (white arrow).

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Figure 3
Computed tomography angiography of the thoracic region with upper limb hyperabduction in the first case. The coronal view shows compression of the right subclavian artery (black arrow), by the clavicle (black arrowhead), first rib (white arrowhead), and cervical rib (white arrow). Mild thickening of the artery wall was also observed, but without causing significant stenosis. No aneurysm was observed.

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Figure 4
Intraoperative image from case 1. (A) Right supraclavicular approach with observation of the phrenic nerve (red strap) and the anterior scalene muscle (EA); (B) After anterior scalenectomy, the cervical rib was identified (black arrow); (C) After medial scalenectomy and resection of the cervical rib and first rib, the subclavian artery (*) was free from compression, with mild thickening of its wall, but without attenuation of pulsation; (D) Surgical specimens: first rib (black arrowhead) and cervical rib (white arrowhead).

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Figure 5
Image of the patient from the second case, showing pulsatile mass in the left supraclavicular fossa.

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Figure 6
Anteroposterior cervical X-ray from the second case showing a cervical rib joined to the first right rib (white arrow).

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Figure 7
Computed tomography angiography of the thoracic region with upper limbs in hyperabduction, from the second case. The three-dimensional reconstruction shows compression of the left subclavian artery between the clavicle (black arrowhead), first rib (black arrow), and cervical rib (white arrow). Aneurysm formation was observed distal of the compression (white arrowhead).

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Figure 8
Intraoperative image from case 2. (A) Left supraclavicular approach with observation of the phrenic nerve (yellow strap), the subclavian artery (ASC), and the anterior scalene muscle (EA); (B) After anterior scalenectomy, the cervical rib (black arrow) and aneurysm (*) were identified; (C) After medial scalenectomy and resection of the cervical rib, the aneurysm was identified (*). The outlet was free from compression; (D) The aneurysm was resected and the artery was reconstructed with end-to-end anastomosis with interrupted stitches, using the Carrel triangulation technique.

Figure 1 Image showing the hyperabduction maneuver in the first case. The patient raises her arms at 180º. Pallor is observed and the distal pulses disappears in the affected limb (right).

Figure 2 Anteroposterior cervical X-ray of the first case showing the cervical rib joined to the first right rib (black arrow). An elongated transverse process of C7 was also observed on the left (white arrow).

Figure 3 Computed tomography angiography of the thoracic region with upper limb hyperabduction in the first case. The coronal view shows compression of the right subclavian artery (black arrow), by the clavicle (black arrowhead), first rib (white arrowhead), and cervical rib (white arrow). Mild thickening of the artery wall was also observed, but without causing significant stenosis. No aneurysm was observed.

Figure 4 Intraoperative image from case 1. (A) Right supraclavicular approach with observation of the phrenic nerve (red strap) and the anterior scalene muscle (EA); (B) After anterior scalenectomy, the cervical rib was identified (black arrow); (C) After medial scalenectomy and resection of the cervical rib and first rib, the subclavian artery (*) was free from compression, with mild thickening of its wall, but without attenuation of pulsation; (D) Surgical specimens: first rib (black arrowhead) and cervical rib (white arrowhead).

Figure 5 Image of the patient from the second case, showing pulsatile mass in the left supraclavicular fossa.

Figure 6 Anteroposterior cervical X-ray from the second case showing a cervical rib joined to the first right rib (white arrow).

Figure 7 Computed tomography angiography of the thoracic region with upper limbs in hyperabduction, from the second case. The three-dimensional reconstruction shows compression of the left subclavian artery between the clavicle (black arrowhead), first rib (black arrow), and cervical rib (white arrow). Aneurysm formation was observed distal of the compression (white arrowhead).

Figure 8 Intraoperative image from case 2. (A) Left supraclavicular approach with observation of the phrenic nerve (yellow strap), the subclavian artery (ASC), and the anterior scalene muscle (EA); (B) After anterior scalenectomy, the cervical rib (black arrow) and aneurysm () were identified; (C) After medial scalenectomy and resection of the cervical rib, the aneurysm was identified (). The outlet was free from compression; (D) The aneurysm was resected and the artery was reconstructed with end-to-end anastomosis with interrupted stitches, using the Carrel triangulation technique.

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Surgical treatment of cervical rib-associated arterial thoracic outlet syndrome

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.