Cornelis G. Vos

Outcome of Surgical Treatment for Thoracic Outlet Syndrome: Systematic Review and Meta-Analysis

BACKGROUND Many publications report outcomes of surgical treatment for thoracic outlet syndrome (TOS); however, high-quality reviews and meta-analyses are lacking. This systematic review and meta-analysis summarizes and compares the outcomes and major complications of the surgical procedures for the 3 types of TOS: arterial, venous, and neurogenic. METHODS MEDLINE, EMBASE, and CINAHL databases, and the Cochrane Database of Systematic Reviews were searched for papers published between January 1980 and February 2015, using the keywords thoracic outlet syndrome, and treatment and surgical. Articles were eligible for inclusion if the following criteria were met: studies describing outcomes of surgery for TOS, published in English, human studies, and available full-text. The exclusion criteria were case-series and case reports (n < 5), reviews, abstracts, and studies of endoscopic-assisted or robotic endoscopic-assisted transaxillary first rib resection. RESULTS A total of 12 papers met our inclusion criteria and were finally included in this systematic review. All included articles showed improvement of complaints after surgical treatment. In our meta-analysis, improvement to Derkashs classification category excellent/good was achieved in 90% of the arterial and venous TOS groups. Preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand scores show improvement of 28.3 points after operative treatment of neurogenic TOS. CONCLUSIONS In conclusion, surgical treatment of TOS seems to be beneficial in most patients and is relatively safe. The largest challenge remains the diagnosis of TOS, especially neurogenic TOS, because standardized diagnostic criteria are lacking. Future studies should focus on the diagnostic work-up of TOS.

Venous Arterialisation for Salvage of Critically Ischaemic Limbs: A Systematic Review and Meta-Analysis.

BACKGROUND Critical limb ischaemia (CLI) is the end stage of peripheral artery disease (PAD) and is associated with high amputation and mortality rates and poor quality of life. For CLI patients with no revascularisation options, venous arterialisation could be a last resort for limb salvage. OBJECTIVE To review the literature on the clinical effectiveness of venous arterialisation for lower limb salvage in CLI patients with no revascularisation options. METHOD Different databases were searched for papers published between January 1966 and January 2016. The criteria for eligible articles were studies describing outcomes of venous arterialisation, published in English, human studies, and with the full text available. Additionally, studies were excluded if they did not report limb salvage, wound healing or amputation as outcome measures. The primary outcome measure was post-operative limb salvage at 12 months. Secondary outcome measures were 30 day or in-hospital mortality, survival, patency, technical success, and wound healing. RESULTS Fifteen articles met the inclusion criteria. The included studies described 768 patients. According to the MINORS score, methodological quality was moderate to poor. The estimated pooled limb salvage rate at one year was 75% (0.75, 95% CI 0.70-0.81). Thirty day or in-hospital mortality was reported in 12 studies and ranged from 0 to 10%. Overall survival was reported in 10 studies and ranged from 54% to 100% with a mean follow-up ranging from 5 to 60 months. Six studies reported on patency of the venous arterialisations performed, with a range of 59-71% at 12 months. CONCLUSION In this systematic review on venous arterialisation in patients with non-reconstructable critical limb ischaemia, the pooled proportion of limb salvage at 12 months was 75%. Venous arterialisation could be a valuable treatment option in patients facing amputation of the affected limb; however, the current evidence is of low quality.

Long-Term Functional Outcome of Surgical Treatment for Thoracic Outlet Syndrome

First rib resection for thoracic outlet syndrome (TOS) is clinically successful and safe in most patients. However, long-term functional outcomes are still insufficiently known. Long-term functional outcome was assessed using a validated questionnaire. A multicenter retrospective cohort study including all patients who underwent operations for TOS from January 2005 until December 2016. Clinical records were reviewed and the long-term functional outcome was assessed by the 11-item version of the Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Sixty-two cases of TOS in 56 patients were analyzed: 36 neurogenic TOS, 13 arterial TOS, 7 venous TOS, and 6 combined TOS. There was no 30-day mortality. One reoperation because of bleeding was performed and five patients developed a pneumothorax. Survey response was 73% (n = 41) with a follow-up ranging from 1 to 11 years. Complete relief of symptoms was reported postoperatively in 27 patients (54%), symptoms improved in 90%, and the mean QuickDASH score was 22 (range, 0–86). Long-term functional outcome of surgical treatment of TOS was satisfactory, and surgery was beneficial in 90% of patients, with a low risk of severe morbidity. However, the mean QuickDASH scores remain higher compared with the general population, suggesting some sustained functional impairment despite clinical improvement of symptoms.

Subtraction computed tomography imaging to detect endoleaks after endovascular aneurysm sealing with sac anchoring

Background Early detection of small type I endoleaks after endovascular aneurysm sealing is mandatory because they can rapidly progress and lead to severe complications. Recognition of endoleaks can be challenging due to the appearances on computed tomography unique to endovascular aneurysm sealing. We aimed to validate the accuracy and added value of subtraction computed tomography imaging using a post-processing software algorithm to improve detection of endovascular aneurysm sealing-associated endoleaks on postoperative surveillance imaging. Methods The computed tomography scans of 17 patients (16 males; median age: 78, range: 72–84) who underwent a post-endovascular aneurysm sealing computed tomography including both non-contrast and arterial phase series were used to validate the post processing software algorithm. Subtraction images are produced after segmentation and alignment. Initial alignment of the stent segmentations is automatically performed by registering the geometric centers of the 3D coordinates of both computed tomography series. Accurate alignment is then performed by translation with an iterative closest point algorithm. Accuracy of alignment was determined by calculating the root mean square error between matched 3D coordinates of stent segmentations. Results The median root mean square error after initial center of gravity alignment was 0.62 mm (IQR: 0.55–0.80 mm), which improved to 0.53 mm (IQR: 0.47–0.69 mm) after the ICP alignment. Visual inspection showed good alignment and no manual adjustment was necessary. Conclusions The possible merit of subtraction computed tomography imaging for the detection of small endoleaks during surveillance after endovascular aneurysm sealing was illustrated. Alignment of different computed tomography phases using a software algorithm was very accurate. Further studies are needed to establish the exact role of this technique during surveillance after endovascular aneurysm sealing compared to less invasive techniques like contrast-enhanced ultrasound.

Patch Angioplasty or Primary Closure Following Carotid Endarterectomy for Symptomatic Carotid Artery Stenosis

Objectives  Guidelines recommend routine patching to prevent restenosis following carotid endarterectomy, mainly based on studies performed many years ago with different perioperative care and medical treatment compared with current standards. Aim of the present study was to compare primary closure (PRC) versus patch closure (PAC) in a contemporary cohort of patients. Methods  Consecutive patients treated by carotid endarterectomy for symptomatic stenosis between January 2006 and April 2016 were retrospectively analyzed. Primary outcome was restenosis at 6 weeks and 1 year and occurrence of ipsilateral stroke. Secondary outcomes were mortality, complications, and reintervention rates. Results  Five hundred carotid artery endarterectomies were performed. Fifty-nine patients were excluded because eversion endarterectomy was performed or because they were asymptomatic. PRC was performed in 349 and PAC in 92 patients. Restenosis at 6 weeks was 6.0% in the PAC group versus 3.0% in the PRC group ( p  = 0.200). Restenosis at 1 year was 31.6 versus 14.1%, respectively ( p  = 0.104). No difference was found for stroke (3.4 vs 1.1%, p  = 0.319), death (1.1 vs 0.0%, p  = 0.584), or other complications (1.1 vs 0.0%, p  = 0.584), respectively. Conclusions  It remains unclear whether routine patching should be recommended for all patients. A strategy of selective patching compared with routine patching, based on internal carotid artery diameter and other patient characteristics, deserves further investigation.

The BeGraft Balloon Expandable Covered Stent as a Proximal Extension to an Iliac Branch Device for Endovascular Repair of Isolated Common Iliac Artery Aneurysms

Introduction Isolated common iliac artery aneurysms (CIAA) are rare and can be treated by endovascular exclusion using iliac branch devices (IBD). The use of a balloon expandable covered stent as a proximal extension to an IBD to allow adequate sealing in the proximal common iliac artery (CIA) for exclusion of isolated CIAA is demonstrated. Report Two patients with isolated CIAA of ≥4.5 cm with a proximal neck length of ≥20 mm (patient A: 26 mm; patient B: 24 mm) and a neck diameter of ≤20 mm (patient A: 16.4 mm; patient B: 15.6 mm) were treated by combining a Zenith IBD with an aortic BeGraft balloon expandable covered stent. After deploying the BeGraft covered stent at 12 mm a second balloon was used to further dilate the proximal part of the stent outside the IBD to allow adequate sealing in the CIA. Completion angiography and follow up computed tomography angiography 1 month post-operatively showed adequate sealing and no endoleaks. Discussion The feasibility of the application of a balloon expandable covered stent as a proximal extension to an IBD for isolated CIAA was demonstrated. It is not necessary to insert an aortic bifurcation endograft, thus reducing procedure time, radiation exposure, contrast use, and cost. A patent inferior mesenteric artery and lumbar arteries can be spared and procedures that require crossing over the aortic bifurcation remain possible. Comorbidity, prior interventions, and disease extension can make this endovascular approach preferred over open repair. Isolated CIAA can be efficiently treated combining the BeGraft balloon expandable covered stent and IBD, which allows proximal sealing in the CIA.

Commentary on ‘Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome’

George et al . presented an innovative approach with excellent results in a series of 10 patients treated with a complete thoracoscopic first rib resection for thoracic outlet syndrome (TOS) (1). Their video assisted thoracoscopic approach resulted in a complete resolution of symptoms in all patients after a follow-up of 6 months without major complications. Main advantages of the technique described are the superior visualization due to the magnified video-assisted thoracoscopic view, and perfect illumination by the scope allowing complete resection of the first rib. Theoretically this might improve results and reduce recurrence rates because presence of a long posterior first rib stump was found to be a strong predictor of poor outcome and residual complaints (2).