Subclavian artery resection and reconstruction for thoracic inlet cancer: 25 years of experience

Abstract

Background: The purpose of this study was to evaluate long-term outcomes after subclavian artery resection and reconstruction during surgery for thoracic inlet cancer through the anterior transclavicular approach.

Methods: Between 1985 and 2011, 72 patients (51 men and 21 women; mean age, 51 years) underwent en bloc resection of thoracic inlet non-small cell lung cancer (n=59), sarcoma (n=10), breast carcinoma (n=2) or thyroid carcinoma (n=1) involving the subclavian artery. An L-shaped transclavicular cervicothoracotomy was performed, with posterolateral thoracotomy in 14 patients or a posterior midline approach in 13 patients. Resection extended to the chest wall (more than two ribs, n=53), lung (n=66), and spine (n=13). Revascularization was by end-to-end anastomosis (n=40), polytetrafluoroethylene graft interposition (n=25), subclavian-to-common carotid artery transposition (n=6), or grafting of the autologous superficial femoral artery in an anterolateral thigh free flap (n=1). Complete R0 resection was achieved in 65 patients and microscopic R1 resection in 7 patients. Postoperative radiation therapy was given to 46 patients.

Results: There were no cases of postoperative death, neurologic sequelae, graft infection or occlusion, or limb ischemia. Postoperative morbidity consisted of pneumonia (n=16), phrenic nerve palsy (n=2), recurrent nerve palsy (n=2), bleeding (n=3), acute pulmonary embolism (n=1), cerebrospinal fluid leakage (n=1), chylothorax (n=1), and wound infection (n=1). Five-year survival and disease-free survival rates were 28% and 20%, respectively. Long-term survival was not observed after R1 resection.

Conclusions: Subclavian arteries invaded by thoracic inlet malignancies can be safely resected and reconstructed through the anterior transclavicular approach, with good long-term survival provided complete R0 resection is achieved.

Keywords: 10.