Costoclavicular Space

Tears in the venous wall of the innominate vein and SVC have been reported with the Excimer sheath [34-39], as has cardiac tamponade due to lasing into the heart [22]. The inability of the laser technique to overcome calcified scar tissue and to perform dilation near the tip of the lead are major limitations [19]. Laser sheaths have a larger diameter compared with mechanical sheaths, and advancing them through the costoclavicular space is often difficult. Another limitation is the consistently higher cost of equipment and sheaths. Despite these disadvantages, this technique spreads rapidly and is today the most commonly used technique in the USA [9, 11]. Whereas earlier studies addressed the efficacy and safety of the initial laser sheath models [36], the recent Lead Extraction in the Contemporary Setting (LExICon) Study [40]... 

Fig. 24.16a,b. Bilateral thoracic outlet syndrome explored with CT imaging with the arms alongside the body (a) and after elevation of the arms (b). Compression of the subclavian artery in the entrance of the costoclavicular space (arrows) is well demonstrated after elevation of the arms... 

The lirst rib is probably the rib most commonly involved in somatic dysfunction of all the ribs. It is affected by trauma, stress, and posture as well as by dysfunction ofthe C7-T1 complex. The patient may report "shoulder" pain, stiff neck, upper back or neck pain, and an inability to turn the head while driving. The first rib can impinge the neurovascular bundle as it passes between it and the clavicle through the costoclavicular space. The anterior and middle scalene muscles, which raise the first rib, may likewise compress the brachial plexus when they are in spasm and result in thoracic outlet syndrome symptoms. The patient s symptoms are then described as pain, numbness, or paresthesias ofthe arm or hand on the involved side. The physician needs to be aware that this may cause confusion should the patient demonstrate a herniated cervical disc on magnetic resonance imaging [MRO. The symptoms may be caused by the rib dysfunction rather than the herniated disc, so evaluation ofthe rib for normal motion and treatment of any dysfunction should be performed in these cases. Osteopathic manipulation may save the patient unnecessary surgery. 

This case is a good example of multiple impingement syndromes. Besides the obvious carpal tunnel, A.M. had some additional impingement of the median nerve as it passes by the pronator teres. The tension in the soft tissues at the thoracic inlet impinged the nerves of the brachial plexus as they passed through the costoclavicular space. It is important to remember that when there is a fall on the rigid arm, the force is transmitted all the way to the neck. In A.M. s case,... 

The thoracic outlet region includes the brachial plexus nerves and the subclavian artery and vein. These neurovascular structures traverse restricted spaces in which they can be compressed, the most important of which are the interscalene triangle, the costoclavicular space and the retropectoralis minor space (Fig. 6.16a) (Demondion et al. 2000). Both subclavian artery and brachial plexus nerves pass through the interscalene triangle, a space bordered by the anterior scalene musde anteriorly, the middle scalene muscle posteriorly and the first rib inferiorly. 

It is important to maintain the patient in the anatomic position. Maneuvers that artificially open the costoclavicular and infraclavicular spaces should be avoided. The common practices of placing towels between the scapulae or extending the arm may result in undesirable puncture of the costoclavicular ligament or subclavius mnscle. The medial venous puncture clearly increases the success rate as well as dramatically reduces the risk of pneumothorax and vascular injury. 

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