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Back in the Swing After Vascular Surgery

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Posted by Temple Heart & Vascular Institute

Sixteen-year-old Ian Turner lives to play tennis. His mother, Karen, describes her son as a positive, hardworking student and athlete who has “given up a lot to pursue his sport.” That includes enrolling in a private cyberschool program that gives Ian and his family, who live in Abington Township, more control over his training schedule.

So when Ian’s dominant hand, arm, and shoulder began to ache in early February, Karen and Ian promptly sought treatment for what they believed to be tennis elbow — a common orthopedic issue.

But physical therapy didn’t bring Ian relief. Even worse, his hand started to cool and turn different colors, prompting Ian and his parents to seek a different diagnosis for the troubling symptoms.

“He just got worse and worse and wasn’t responding to treatment,” Karen says. “It was three weeks of appointments as we tried to figure out what this was, and meanwhile, he was suffering a lot. He had little use of his hand for weeks, it kept him up during the night, and he couldn’t even write or do his schoolwork. It was hard to watch.”

When one doctor discovered a lump in Ian’s neck, he was sent for further tests and eventually landed at Temple University Hospital. “We all felt it was an emergency, and I knew Temple has an excellent vascular program,” Karen says. “That’s where the diagnosis was heading at this point. We learned after tests at Temple that not only did Ian have an aneurysm—a bulging blood vessel— but he had debilitating blood clots in his arm and hand. None of those showed on the MRIs.”

That’s because Ian didn’t have an orthopedic issue—he had what’s known as thoracic outlet syndrome. The disorder, which recently sidelined New York Mets ace pitcher Matt Harvey, arises from compression of the arteries, veins, and nerves in the thoracic outlet, a small space underneath the clavicle (breastbone). According to Scott Golarz, MD, FACS, a vascular surgeon in the Temple Heart & Vascular Institute, “The majority of thoracic outlet patients we care for have severe compression of the nerves. These tend to be young or working-age people who use their arms and shoulders in the course of their jobs. But occasionally we see the arterial variety, which can be very dangerous.”

“Some of us are born with rare anatomic variants; in Ian’s case it was an extra rib,” he continues. “Over time and especially with repetitive use (as with sports) this can progressively damage the artery, nerves, and veins as they pass through the shoulder. In its most dangerous form, the artery is so badly damaged that it grows and can even throw off clots. It’s these clots that can damage and even destroy the arm and hand.”

But getting the right treatment—and the right diagnosis—can be tricky, especially since thoracic outlet syndrome resembles many other common disorders and doctors aren’t always looking for it. “It’s underdiagnosed and undertreated when it is diagnosed,” Dr. Golarz says. “Most patients have arm, chest, or shoulder pain that radiates to the head, chest, and hand. They bounce around from neurologists to orthopaedic specialists to psychiatrists. Since there’s no one test we can use to diagnose the syndrome, it’s important to be seen by an experienced provider who knows how the pieces of the puzzle fit together.”

This three-dimensional reconstruction shows the arterial aneurysm in relation to the bony structures of the thoracic outlet. The cervical rib (highlighted in yellow) and first rib (highlighted in blue) are compressing the artery and the aneurysm (the walnut shell-shaped bulge highlighted in red) is in the subclavian artery.

Fortunately for Ian, Dr. Golarz diagnosed his thoracic outlet syndrome and corrected the problem through decompression surgery, a complex procedure that involved removing a rib and part of a muscle and then cleaning up nerve damage and scar tissue around the nerves.

“The purpose of decompression surgery is to open up the area,” Dr. Golarz says. “I removed his first rib and the cervical rib and used a piece of vein from his leg to recreate the artery that had been destroyed under the clavicle. We also removed clots from his arm and reconstructed those arteries. After surgery, we put him on blood thinners and waited for him to respond.”

To everyone’s relief, Ian’s hand was warm and pink the next day.

“With Ian, we pulled out all the stops—he could have lost his hand or it could have been functionless if we hadn’t done the surgery,” Dr. Golarz says. “He has regained normal blood flow and now has full use of the arm and hand. I have story after story of people who improve, just like Ian, after successful decompression surgery.”

For most varieties of thoracic outlet syndrome, surgery leads to significant and lasting improvement for the vast majority of patients, though some need physical therapy and careful monitoring after surgery. Ian, whose surgery took place March 2nd, falls into that category. “There is very little chance of recurrence, but we will watch the vein over time to make sure nothing abnormal develops,” explains Dr. Golarz. “However, Ian’s recovery is astonishing. He is actually back playing tennis and doing better than before the operation.”

That smooth transition is the result of hard work and cautious strategy. “Ian worked very closely with his personal trainer who helped facilitate his recovery and get him back on the courts,” Karen says. “Fortunately, as the days and weeks and months passed since his surgery, he’s just gotten better and better.”

Ian will continue to be monitored and remain vigilant for signs of problems, but Karen is optimistic that the worst of it is behind them. “To tell anyone that you can’t use your hand is horrible, but we were worried that maybe he would never even pick up a tennis racket again,” she says. “Now, my son is totally back to normal, back to playing the sport he loves.”

“I was pretty worried about having the surgery, with such a long hospital stay and recovery time,” admits Ian. “But I’ve worked hard to get back my strength, mobility, and range of motion.” Rehabbing the arm carefully and correctly has been key, since Ian has a one-handed backhand— meaning he uses his right arm for both forehand and backhand shots as well as serves. “I’m still building from where I left off,” he says, “but I feel great—back to normal, or even better.”

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