Thoracic surgery for improving arterial and venous blood flow in the upper extremity.

This thesis describes different aspects of both arterial and venous disease of the upper extremities. PART 1 of the thesis encompasses studies on the treatment of ischemia of the hand and fingers by means of a thoracic sympathectomy. CHAPTER 2 and 3 are literature reviews on the outcome of thoracic sympathectomy in the management of upper limb ischemia. Short-term and long-term beneficial effects were reported. Ulcer healing or improved healing was seen in almost all patients. The reported effect decreased over time. The results of 35 patients with upper extremity ischemia treated with Endoscopic Thoracic Sympathectomy (ETS) in our institution are reported in CHAPTER 4. Long-term beneficial effect of ETS was reported in 53%. In CHAPTER 5 we tested a novel robot assisted technique with the use of the Da Vinci® surgical robot to perform a T2-T5 ramicotomy in a porcine model. The procedure was successfully completed in all 5 animals. PART 2 of this thesis is focused on the treatment of patients with venous thoracic outlet syndrome. CHAPTER 6 serves as an introduction to the second part of this thesis by presenting an illustrative case of a young, healthy, athletic male with upper extremity deep venous thrombosis. The results of patients with Paget-Schroetter syndrome (PSS) treated in our institution between 1990 and 2015 were retrospectively analysed in CHAPTER 7. In total 67 of 91 patients returned their questionnaires. Functional outcomes were better in the surgical group compared to the non-operative treated patients. Surgery made it more likely to continue original lifestyle and sports activities. A prospective case series of 24 patients with PSS, who were scheduled to undergo first rib resection (FRR) is presented in CHAPTER 8. Patients were divided in primary(p)-FRR or on-demand(OD)-FRR. DASH scores at follow up did not differ significantly between P-FRR and OD-FRR patients. Recurrence of thrombosis was more frequent in the OD-FRR group and was associated with worse postoperative DASH scores. In CHAPTER 9 we systematically reviewed the literature from 1990 to 2021 on the management of PSS. Sixty reports were included with a total of 2653 patients. Patients were categorized by therapy in four main groups: anticoagulation (AC); catheter directed thrombolysis followed by anticoagulation (CDT+AC); anticoagulation with subsequent first rib resection (AC+FRR) and catheter directed thrombolysis prior to first rib resection (CDT+FRR). The most favourable outcomes were noted in patients treated with CDT+FRR. In CHAPTER 10 we describe the initial results of a novel surgical approach for first rib resection using the Da Vinci® surgical robot. We performed this transthoracic technique with only three access ports (trocars). The results of 15 procedures are presented. Main Conclusions There is evidence to support the option of performing an endoscopic thoracic sympathectomy in a selected group of patients with primary Raynaud’s disease or secondary Raynaud’s phenomenon, in which the results of supportive and nonoperative therapies have been insufficient. Robot assisted ramicotomy is feasible and effective. Our literature review and retrospective study show better results in surgically treated PSS patients compared to the non-operative group. Nevertheless, a substantial part of non-operative treated patients will become symptom free with non-operative therapies. Robot assisted first rib resection is an effective minimal invasive treatment with excellent functional outcome. The information provided by this thesis can aid the shared decision making with patients diagnosed with upper extremity ischemia and PSS. It is clear that all patients have different perspectives on health and are willing to endure different risks in the pursuit of a cure for their complaints. Surgeons should be committed to take these personal considerations into account and counsel patients to their most suitable personalized therapy.