A Systematic Review and Meta-Analysis of Surgical Approaches for Venous Thoracic Outlet Syndrome

Introduction: There is currently no consensus on the optimal surgical approach for the treatment of venous thoracic outlet syndrome (vTOS). Surgical exposures for vTOS decompression include infraclavicular (IC), supraclavicular (SC), paraclavicular (PC), and transaxillary (AX) approaches. The purpose of this study is to provide a comprehensive review of the outcomes and major complications of these four surgical techniques.

Methods: This meta-analysis was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We performed a systematic search in the Cochrane Library trials register, Scopus, PubMed, EMBASE, Google Scholar, and the US National Library of Medicine clinical trial databases for studies that evaluated the above four surgical exposures for vTOS and included them. Three independent reviewers assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Primary outcomes of interest were clinical improvement and postoperative primary patency rate. Secondary outcomes included rates of nerve injury, hematoma, hemothorax, pneumothorax, and other complications. Pooled proportions with 95% confidence intervals (CIs) of various outcomes were calculated using a random-effects model. Subgroup analyses according to surgical approach were conducted.

Results: A total of twenty-six studies were included in the final analysis. The cumulative number of studies by surgical approach was 8 IC, 5 SC, 6 PC, and 11 AX. Pooled results from these studies demonstrated a 0.94 clinical improvement following surgical intervention (95% CI, 0.87-1), with a rate of 1 (95% CI, 0.99-1) for IC, 0.84 (95% CI, 0.38-1) for SC, 0.97 (95% CI, 0.76-1) for PC, and 0.88 (95% CI, 0.78-0.96) for AX approach. Overall, postoperative patency rate was 0.92 (95% CI, 0.84-0.97), with rate of 0.95 (95% CI, 0.89-1) for IC, 0.95 (95% CI, 0.78-1) for SC, 1 (95% CI, 0.98-1) for PC, and 0.69 (95% CI, 0.54-0.82) for AX approach. Subgroup analysis demonstrated a significantly higher rate of clinical improvement (0.12) in the IC group compared to the AX group. Rates of postoperative primary patency were higher in the IC (0.26), SC (0.26), and PC (0.31) groups than the AX group.

Conclusions: Our study highlights the importance of considering different surgical approaches for the decompression of vTOS. While the IC, SC, and PC methods demonstrate comparable postoperative primary patency and clinical improvement, the AX approach shows lower outcomes in these aspects. Surgeons should carefully weigh the benefits and limitations of each approach when determining the most suitable surgical technique for vTOS patients.