Gregory J. Pearl M.D.

Beteck, B., W. Shutze, B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola and G. Pearl (2019). “Comparison of Athletes and Nonathletes Undergoing Thoracic Outlet Decompression for Neurogenic Thoracic Outlet Syndrome.” Ann Vasc Surg 54: 269-275.

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome (TOS) and may occur from injury, occupational stress, or athletic endeavors. Although most patients with NTOS will improve after first-rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than nonathletes. We hypothesized that athletes would do better after FRRS than nonathletes despite the added physical stress that sporting activity imposes. METHODS: We reviewed our office records for all patients treated for TOS from July 2009 to May 2014 and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS and compared athlete versus nonathlete survey responses. RESULTS: Five hundred sixty-four patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were nonathletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. nonathletes 80%, P = 0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs. nonathletes 79%, P = 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. nonathletes 65%, P = 0.02), and 86% could perform activities of daily living without limitation (athletes 95% vs. nonathletes 77%, P = 0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. nonathletes 22%, P = 0.6), 89% felt that they had made the right decision (athletes 93% vs. nonathletes 80%, P = 0.09). Multivariable analysis of age, race, gender, previous surgery, preoperative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living. CONCLUSIONS: Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. Although being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction after FRRS was similar to that in nonathletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors.

Beteck, B., W. Shutze, B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola and G. Pearl (2018). “Comparison of athletes and non-athletes undergoing thoracic outlet decompression for neurogenic TOS.” Ann Vasc Surg Aug 3. [Epub ahead of print].

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of TOS and may occur from injury, occupational stress or athletic endeavors. While most patients with NTOS will improve after first rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than non-athletes. We hypothesized that athletes would do better after FRRS than non-athletes despite the added physical stress that sporting activity imposes. METHODS: We reviewed our office records for all patients treated for TOS from July 2009 to May 2014, and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS, and compared athlete versus non-athlete survey responses. RESULTS: 564 patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were non-athletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. non-athletes 80%, p=0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs non-athletes 79%, p= 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. non-athletes 65%, p=0.02), 86% could perform activities of daily living without limitation (athletes 95% vs. non-athletes 77%, p=0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. non-athletes 22%, p=0.6), 89% felt that they had made the right decision (athletes 93% vs. non-athletes 80%, p=0.09). Multivariable analysis of age, race, gender, previous surgery, pre-operative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living. CONCLUSION: Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. While being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction following FRRS was similar to that in non-athletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors.

Shutze, W., B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola, A. Young and G. Pearl (2017). “Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome.” J Vasc Surg 66(6): 1798-1805.

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) results from compression of the brachial plexus by the clavicle, first rib, and scalene muscles and may develop secondary to repetitive motion of the upper extremity. Athletes routinely perform repetitive motions, and sports requiring significant arm and shoulder use may put the participant at increased risk for NTOS. Competitive athletes who develop NTOS may require first rib resection and scalenectomy (FRRS) for symptomatic relief. However, the effectiveness of FRRS has not previously been studied in this vulnerable population. METHODS: This is a cross-sectional study of competitive athletes with NTOS who received FRRS by the senior author between 2009 and 2014. Eligible patients were contacted by phone and invited to complete a nine-item survey assessing the long-term effects of FRRS on pain medication use, postoperative physical therapy duration, patient satisfaction, symptom relief, activities of daily living, athletic performance, time to return of athletic performance, and need for other operations. Multivariate analyses of the following risk factors were performed: age, pectoralis minor release, preoperative narcotic use, athletic shutdown, and involvement in a throwing sport. RESULTS: There were 232 competitive athletes who met the inclusion criteria, and 67 of these (age, 14-48 years; 35 male; 99% white) responded to the survey. The average time between surgery and survey completion was 3.9 years (range, 2.2-7.0 years). The most frequent sports conducted by this group were baseball and softball (n = 44 [66%]), volleyball (n = 7 [10%]), and cheerleading and gymnastics (n = 5 [7%]), ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%. Multivariate regression analysis identified younger age as a predictor of the length of physical therapy and preoperative narcotics use as a predictor of symptom resolution. CONCLUSIONS: At our center, >40% of patients requiring FRRS for NTOS are competitive athletes. The results of this study show that the majority of them are able to return to their precompetitive state after FRRS, and few experience limitations in their daily living activities. Half can return to competition at or exceeding their premorbid ability level within 6 months of surgery. The majority are pleased with their decision to undergo FRRS. Further investigation is needed to identify predictive factors for successful return to competitive athletics.

Rios, A., P. Parsa, J. Eidt and G. Pearl (2017). “A novel surgical approach to symptomatic left renal vein aneurysm.” J Vasc Surg Venous Lymphat Disord 5(6): 875-877.

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Visceral venous aneurysms are uncommon and renal vein aneurysms are among the rarest in this subset. Renal vein aneurysms are frequently asymptomatic, but patients may present with flank pain or hematuria. Complications of untreated visceral venous aneurysms include thrombus formation and, very rarely, rupture. Treatment of renal vein aneurysms ranges from watchful waiting to surgical repair. We describe a patient with renal vein aneurysm presenting with recurrent pulmonary embolus with no other identifiable source. Furthermore, we propose a novel surgical treatment with complete resection of the aneurysm and reconstruction of venous return by transposing the inferior mesenteric vein to the remaining left renal vein.

Parsa, P., K. Cantu, J. Eidt, D. Gable and G. Pearl (2017). “Case report: A durable open repair of a rare profunda aneurysm.” Ann Vasc Surg 44: 424.e427-424.e410.

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Profunda femoris artery aneurysms (PFAAs) are rare and difficult to diagnose in the early stages of development due to location and encasement in the deep thigh musculature. We report the case of a 74-year-old male who was discovered to have a right PFAA during evaluation for progressively worsening short distance claudication. He had undergone an angioplasty of the left iliofemoral system several months ago with no improvement of his symptoms. The PFAA was diagnosed through computed tomography angiography and repaired via syndactylization of profunda femoris branches and interposition grafting with a polytetrafluoroethylene stretch graft. The imaging features are described in the article. Although PFAAs are rare clinical presentations, their development should be considered, in particular when symptoms such as progressive or unchanging claudication are present in a patient following an angioplasty of the affected iliofemoral system.