Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Interventional Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
J Endovasc Ther. 2023 Jun;30(3):355-363. doi: 10.1177/15266028221081078. Epub 2022 Mar 8.
The aim of this paper was to report our experience with arterial and venous endovascular stent placement in the thoracic outlet (TO) and review available literature.
All patients that underwent arterial or venous stent placement in the TO between 2013 and 2020 in 5 Dutch vascular teaching-hospitals were retrospectively identified. Primary endpoint was symptomatic stent failure due to stenosis, chronic or posture dependent compression, fracture, or occlusion of the stent. Secondary endpoints were symptoms at last follow-up and re-interventions. For the literature review, we searched studies reporting on stenting in the TO.
Twenty-six patients were included with 11 arterial and 15 venous stents implanted to treat angioplasty resistant stenosis in arterial or venous TO syndrome, iatrogenic or traumatic vascular injury, radiotherapy fibrosis, or arterial dissection. Median follow-up was 19 and 14 months in the arterial and venous-group, respectively. Eight (73%) patients in the arterial, and 9 (60%) in the venous-group suffered symptomatic stent failure. Seven (64%) patients in the arterial, and 9 (60%) in the venous-group required at least 1 re-intervention. When comparing all patients with stent placement after TO decompression (TOD) to patients without, there were substantially more symptomatic stent failures and re-interventions required in the patients without TOD. Six patients (54%) in the arterial-group and 11 (73%) in the venous-group were symptom-free at last follow-up. Five articles describing 51 patients with arterial and 6 articles describing 81 patients with venous stents were included in the literature review. In the arterial-group, no TOD prior to stent placement was performed, while in the venous-group all but 1 article performed TOD prior to stent placement. Results showed comparable rates of symptomatic stent failure (24% vs 30%), and patients requiring re-interventions (29% vs 21%) between groups.
Based on our multicenter series and review, stents in the TO have a considerable risk of failure, both in the venous and the arterial territory. Especially in patients without TOD: the need for re-interventions is high and half the patients eventually undergo TOD. Based on the currently available data, stenting in the TO should be applied cautiously while TOD should be considered.
本文旨在报告我们在胸廓出口（thoracic outlet，TO）进行动脉和静脉血管内支架置入的经验，并回顾相关文献。
回顾性分析 2013 年至 2020 年期间，荷兰 5 所血管教学医院中所有在 TO 行动脉或静脉支架置入的患者。主要终点是由于狭窄、慢性或体位依赖性压迫、支架断裂或闭塞导致的症状性支架失败。次要终点是最后一次随访时的症状和再介入治疗。为了进行文献复习，我们检索了报道 TO 支架置入的研究。
共纳入 26 例患者，其中 11 例为动脉支架置入，15 例为静脉支架置入，用于治疗动脉或静脉胸廓出口综合征的血管成形术后难治性狭窄、医源性或创伤性血管损伤、放疗纤维化或动脉夹层。动脉组和静脉组的中位随访时间分别为 19 个月和 14 个月。动脉组有 8 例（73%）患者和静脉组有 9 例（60%）患者出现症状性支架失败。动脉组有 7 例（64%）患者和静脉组有 9 例（60%）患者需要至少 1 次再介入治疗。将所有行 TO 减压（thoracic outlet decompression，TOD）后支架置入的患者与未行 TOD 的患者进行比较，发现未行 TOD 的患者发生症状性支架失败和需要再介入治疗的情况明显更多。动脉组有 6 例（54%）患者和静脉组有 11 例（73%）患者在最后一次随访时无症状。文献复习共纳入 5 篇描述动脉支架置入患者（51 例）和 6 篇描述静脉支架置入患者（81 例）的文章。在动脉组，支架置入前未行 TOD，而在静脉组，除 1 篇文章外，其余均在支架置入前行 TOD。结果显示，两组症状性支架失败率（24%比 30%）和需要再介入治疗的患者比例（29%比 21%）相当。
基于我们的多中心系列研究和文献复习，TO 内支架置入的失败风险相当高，无论是在静脉还是动脉区域。特别是在未行 TOD 的患者中，需要再次介入治疗的比例较高，半数患者最终需要行 TOD。根据目前的可用数据，应谨慎应用 TO 支架置入，而应考虑 TOD。
