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

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.