Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
Department of Surgery, University of California San Francisco - East Bay, Oakland, CA.
Ann Vasc Surg. 2021 Apr;72:147-158. doi: 10.1016/j.avsg.2020.10.046. Epub 2021 Feb 3.
Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial, given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher versus lower volume centers.
The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm (arterial [aTOS]), subclavian deep vein thrombosis (venous [vTOS]), or brachial plexus lesions (neurogenic [nTOS]). Basic descriptive statistics, nonparametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher and lower volume hospitals, respectively.
There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010 and 2015 (89.2% nTOS, 9.9% vTOS, and 0.9% aTOS) with annual case volume increasing significantly over time (P = 0.03). Higher volume centers (≥10 cases per year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma, or lymphatic leak) rates (adjusted odds ratio [OR] 0.71 [95% confidence interval 0.52-0.98]; P = 0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 [0.20-2.43]; P = 0.56) or vascular injuries/graft complications (aOR 0.71 [0.0.33-1.54]; P = 0.39). Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (P = 0.03). However, vTOS and aTOS had >2.5 times the odds of major complication compared with nTOS (OR 2.68 [1.88-3.82] and aOR 4.26 [1.78-10.17]; P < 0.001), and ∼10 times the odds of a vascular complication (aOR 10.37 [5.33-20.19] and aOR 12.93 [3.54-47.37]; P < 0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (P < 0.001). Total hospital charges were on average higher when surgery was performed in lower volume centers (<10 cases per year) compared with higher volume centers (mean $65,634 [standard deviation 98,796] vs. $45,850 [59,285]; P < 0.001).
The annual number of TOS operations has increased in the United States from 2010 to 2015, whereas complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher volume centers delivered higher value care: less or similar operative morbidity with lower total hospital charges.
胸廓出口综合征（TOS）手术相对较少且存在争议，因为在诊断方面存在挑战，并且在症状和功能恢复方面存在广泛的差异。我们的目的是在全国代表性队列中测量 TOS 手术的利用趋势、并发症和死亡率，并比较高容量和低容量中心。
使用国际疾病分类第 9 版代码（肋骨切除术和斜角切除术与腋动脉[ATOS]、锁骨下静脉深血栓形成[VTOS]或臂丛病变[神经源性[TOS]）查询国家住院患者样本。使用基本描述性统计、非参数趋势检验和具有中心随机截距的多变量分层回归模型，分别比较 TOS 类型、随时间的趋势以及高容量和低容量医院的结果。
2010 年至 2015 年间共进行了 3547 例 TOS 手术（估计全国有 18210 例 TOS 手术）（89.2% nTOS、9.9% vTOS 和 0.9% aTOS），每年的病例量显著增加（P=0.03）。高容量中心（每年≥10 例）占医院的 5.2%和病例的 37.0%，这些中心的总体主要并发症（定义为神经损伤、动静脉损伤、血管移植物并发症、气胸、出血/血肿或淋巴漏）发生率显著降低（调整后的优势比[OR]0.71 [95%置信区间 0.52-0.98]；P=0.04），但神经并发症（如臂丛损伤）无差异（调整后的 OR 0.69 [0.20-2.43]；P=0.56）或血管损伤/移植物并发症（调整后的 OR 0.71 [0.0.33-1.54]；P=0.39）。总死亡率为 0.6%，神经损伤罕见（0.3%），并发症的比例随时间减少（P=0.03）。然而，与 nTOS 相比，vTOS 和 aTOS 的主要并发症的可能性高 2.5 倍以上（OR 2.68 [1.88-3.82]和 aOR 4.26 [1.78-10.17]；P<0.001），血管并发症的可能性高 10 倍以上（aOR 10.37 [5.33-20.19]和 aOR 12.93 [3.54-47.37]；P<0.001）。随着并发症数量的减少，平均医院费用也随时间显著下降（P<0.001）。与高容量中心（每年≥10 例）相比，低容量中心（每年<10 例）的手术费用平均更高（平均为 65634 美元[标准差 98796]与 45850 美元[59285]；P<0.001）。
从 2010 年到 2015 年，美国 TOS 手术的年度数量有所增加，而并发症和平均医院费用有所下降。死亡率和神经损伤仍然很少见。高容量中心提供了更高的治疗价值：并发症更少或相似，总医院费用更低。
