Complications - Thoracic outlet syndrome (TOS) - Left transaxillary first rib resection (TFRR) - Vascular surgery

Injury to the subclavian vein and artery

• Compression, suture of the vessel
• Injuries to the subclavian vein are difficult to control because the constricted space makes placement of vascular clamps nearly impossible (cell saver, occasional mass transfusion required)

Plexus injury

• e.g. intercostobrachial nerve; long thoracic nerve; dorsal scapular nerve; phrenic nerve
• Iatrogenic sharp plexus injury -> neurosurgeon consult
• if neurosurgeon unavailable: adaptive perineural suture with nonabsorbable monofilament stitches; leave tails long since this facilitates definitive treatment according to the deferred urgency protocol

Secondary bleeding

• Depending on the finding -> evacuate the hematoma and staunch the bleeding or suture the vessel

Pleural injury with hematoma/hydrothorax

• Chest tube, if not already placed intraoperatively

Plexus injury

• Sensory dysfunction, scapular winging with limited ability to elevate the arm above the horizontal, high riding diaphragm with increased risk of pneumonia
• Rare: injury to the stellate ganglion -> ipsilateral Horner syndrome
• Neurology consult and, if necessary, referral to neurosurgery for repair

Recurrence

• Inadequate rib resection
• Hematoma formation with tissue fibrosis

“Other”

• Unfavorable scarring, callus formation at the posterior stump of the rib and/or regeneration from residual costal periosteum -> revision with careful neurolysis, freeing the vessels from scar tissue, and resection of the regenerated osseous tissue (usually as apical pleurectomy)