PURED Procedure for Thoracic Outlet Syndrome

What surgical techniques are used for TOS treatment?

Surgery for thoracic outlet syndrome aims to relieve the pressure on nerves and blood vessels and is called thoracic outlet decompression (TOD). Several surgical techniques are used for TOD. They can be divided into two main groups: with and without rib removal.

TOD without rib removal is performed anteriorly and above the clavicle and is called anterior supraclavicular neurolysis or neuroplasty. This procedure was proposed and used to prevent complications associated with first rib resection.

Removal of the first and accessory ribs (if present) can be performed through anterior (supraclavicular or infraclavicular) or lateral (transaxillary) approach. Endoscope assisted and robotic options are available as well.

What are the factors associated with success of TOS surgery?

The only factor associated with a good outcome after thoracic outlet decompression is the extent to which the first rib is removed. In this context, TOD operations without removing the first rib have the lowest success rate. Patients often feel worse after surgery because of nerve manipulation and scar tissue formation. Contrary, removing the first rib works better. However, complete resection of the first rib is practically impossible using conventional surgical methods. Usually, only the middle portion of the first rib can be removed, and bone stumps attached to the spine and sternum remain after surgery and are the main causes of recurrence.

What is TOS dilemma?

TOS dilemma states that safety and efficacy of thoracic outlet surgery cannot be simultaneously accomplished. The surgeon must compromise one for the sake of the other. The efficacy of TOD surgery is directly related to the aggressiveness of the first rib resection. Aggressive approach nonetheless leads to high surgical morbidity compromising the safety. As a matter of fact, each surgeon should decide for himself on what point of this safety/efficacy spectrum he is. This leads to significant variability of first rib resections among different surgeons. The thoracic outlet dilemma was the single most important unsolved problem in the field of TOS surgery. It was solved in 2015 by Dr. Aghayev’s posterior technique.

What are the reasons for alternative surgical technique

Thoracic outlet syndrome remains one of the most under diagnosed and under treated diseases. More often than not, surgical treatment of TOS is unsuccessful. Whatever surgical technique is employed, first rib removal is always incomplete leading either to suboptimal results or persistence/recurrence. It is hard to believe that with astonishing modern medical achievements complete first rib removal is still a problem. Nevertheless, this is the current situation with thoracic outlet syndrome. Significant number of surgically treated patients do not benefit from surgery, others get worse. PURED was invented to solve this problem and help suffering patients.

PURED PROCEDURE

In 2015 Dr. Aghayev has developed a unique, posterior, minimally invasive approach that allows complete removal of the first/accessory ribs and total decompression of neurovascular bundle. ¹ PURED is an acronym and stands for Posterior Upper Rib Excision and Decompression.

Surgical technique

PURED procedure is performed in several steps or phases. These steps should be fully and flawlessly implemented to ensure the best results. These phases include access, bone removal, neuro-vasculolysis and fat tissue filling.

Access

The procedure is performed from the back with approximately 4 cm (less than 2 inch) skin incision between the scapula and the midline. Underneath the skin there is a natural way between upper back muscles leading to the thoracic outlet area. This triangle shaped area was discovered by Dr. Aghayev in 2017. ² It is filled with loose fat tissue and is very easy to pass through. This way surgeon can access the thoracic outlet area without sacrificing upper back muscles. In addition, this triangle allows excellent working corridor. This way structures of interest (first rib, accessory rib, brachial plexus, subclavian artery and vein) can be exposed effortlessly.

Bone removal

The first and accessory cervical ribs are covered by muscles. Additionally, the first rib is partially hidden under the transverse process of the T1 vertebra. For total removal the surgeon must slowly and carefully remove all bones and muscles covering the ribs to expose them. Only after having full visual control, ribs are resected. The good news is that this part of surgery does not require exposure and manipulation of the brachial plexus. The nerves are very delicate so it is wise to leave them under the “blanket of muscles” until bone removal is finished. Subclavian artery also lies under this blanket and well protected. Only the subclavian vein is exposed during this part due to its relatively large size and immediate proximity to the first rib. Subclavian vein however is very mobile and tolerates retraction very well. The first rib is removed up to all its joints which connect it to the T1 vertebra and sternum. By visually confirming all joint surfaces surgeon validates completeness of the bone removal and ensures that nothing of the rib is left.

Neuro-vasculolysis

First and accessory rib removal provides significant decompression of the subclavian artery and vein and brachial plexus. But soft tissue compression may remain even after complete bone removal. Fortunately, PURED approach allows broad access to the entire neuro-vascular bundle. First the middle scalene muscle is gradually removed exposing the brachial plexus. During this step any abnormal fibrotic, muscular and vascular bands are carefully dissected and cut. Thankfully, first rib resection provides ample space for nerve and vessel manipulation. After finishing with brachial plexus subclavian artery and vein are also freed up from fibromuscular bands. At the end of this phase surgeon has an unobscured view of the entire neuro-vascular bundle.

Fat tissue filling

Wide exposure of the nerves and vessels ensures complete release from compression. Unfortunately broad access invites extensive scar tissue formation. Unlike other surgeries where postoperative fibrosis is not a big problem, thoracic outlet decompression is different. Fibrosis sticks to the brachial plexus and may result in chronic, debilitating neuropathic pain. This type of pain is hard to treat. Luckily PURED procedure provides solution to this problem as well. A small (5 mm) incision is made in the lower back area and subcutaneous fat tissue is harvested by liposuction technique. This fat tissue is then injected into the surgical cavity until it is full. This way nasty scar tissue cannot fill the void space created by bone and muscle removal. Soft and supple fat provides best environment for delicate nerves and vessels and maintains their mobility.

Postoperative care

Following the surgery the patients are transferred to their room. There is no need for intensive care unit (ICU) stay. The patients are mobilized as early as possible. Patients use incentive spirometry to rapidly regain full lung capacity. No antibiotics are given and no infection cases have ever occurred with PURED procedure. Pain is moderate, no narcotic medications are given. Usual hospital stay is 2-3 days. Usually the patients resume normal lifestyle within one month.

Advantages

1. The first and accessory rib removal is easy and safe since there are no overlaying nerves and vessels.
2. The brachial plexus is closest to the skin posteriorly, allowing the surgeon to work in a shallow area. Additionally, subclavian vessels are deeper into the brachial plexus and do not interfere with manipulation. Therefore, decompression is easy, safe, and effective.
3. The most important advantage of the PURE technique is the absence of recurrence due to total resection of the accessory and first ribs.
4. The PURED technique provides a very high level of safety compared to other approaches due to minimal vascular and nerve manipulation.
5. Dr. Aghayev has been performing this procedure for over ten years with more than 200 patients treated. ³ There was no single complication and all patients improved. Some patients had surgery before via the anterior or transaxillary approach. Even in these recurrent cases PURED technique cured all symptoms.

References

1. Aghayev K, Ciklatekerlio O. Posterior Upper Rib Excision for Neurogenic Thoracic Outlet Syndrome—Feasibility and Early Outcomes. Oper Neurosurg (Hagerstown). 2018;14(5): 532-537. https://doi.org/10.1093/ons/opx143[↩]
2. Akaslan I, Ertas A, Uzel M, Ozdol C, Aghayev K. Surgical Anatomy of the Posterior Intermuscular Approach to the Brachial Plexus. Hand (N Y). 2021;16(6): 759-764. https://doi.org/10.1177/1558944719895619[↩]
3. Aghayev K. Safety and Efficacy of Posterior Upper Rib Excision and Decompression Technique for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome. World Neurosurg. 2023;180: e739-e748. https://doi.org/10.1016/j.wneu.2023.10.017[↩]