Vascular thoracic outlet syndrome

Abstract The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib (n = 16), soft tissue anomalies (n = 12), and scar tissue after clavicle fracture (n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia (n = 11), transient ischemic attack (TIA) (n = 1), and claudication or vasomotor phenomena during the arm hyperabduction (n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision (n = 12), combined cervical and first rib excision (n = 4), and first rib excision (n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies. Electronic Publication     

Recurrent thoracic outlet syndrome

Recurrent symptoms develop in 15% to 20% of patients undergoing either first rib resection or scalenectomy for thoracic outlet syndrome. Over the past 22 years 134 operations for recurrence were performed in 97 patients. Four operations were used: transaxillary first rib resection (26); supraclavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial plexus neurolysis (35). Complications included temporary plexus injury (0.7%), temporary phrenic palsy (3.7%), and permanent phrenic palsy (1.4%). The combined primary success rate of all four operations for recurrence was 84% in the first 3 months. This fell to 59% at 1 to 2 years; 50% at 3 to 5 years; and 41% at 10 to 15 years. No significant difference was found in results between the four operations used for recurrence. When recurrence was caused by trauma the results of reoperations were better than when recurrence was spontaneous. The primary success rates of three initial operations for thoracic outlet syndrome were compared to their secondary success rates (improved after reoperation). By use of life-table methods, reoperation improved the 5- to 10-year success rate of transaxillary first rib resection from 69% to 86% and for scalenectomy from 69% to 84%. Reoperation is successful in most cases of recurrent thoracic outlet syndrome and better when recurrence is the result of a neck injury.     

Venous thoracic outlet syndrome

Venous thoracic outlet syndrome is caused by subclavian vein obstruction with or without thrombosis. The primary symptom is arm swelling, frequently accompanied by cyanosis, pain, and occasionally paresthesias. Venography is the only reliable diagnostic tool. Therapy has three goals: (1) remove the thrombus (in thrombotic cases), (2) remove the extrinsic compression, and in a minority of cases, (3) remove the intrinsic stenosis.     

Neurogenic thoracic outlet syndrome

Current concepts for the diagnosis of neurogenic thoracic outlet syndrome are presented together with the surgical experience and results in series of 51 patients caused by a cervical rib. Surgical treatment is recommended in patients with persistent and disabling symptoms not responding to conservative therapy. In carefully selected patients good to excellent results can be achieved.     

Post-traumatic thoracic outlet syndrome

Background  

To evaluate the clinical presentation, diagnostic and therapeutic management and outcome of 27 cases of post-traumatic thoracic outlet syndrome (PT TOS).     

Diagnosing thoracic outlet syndrome

Diagnosing and treating thoracic outlet syndrome can be challenging and frustrating. It must be emphasized that the diagnosis of TOS is a clinical one based on a detailed history and physical examination. This takes time and effort and is often confounded by the patient's research on the internet and emotional problems usually resulting from the symptoms and lack of appropriate treatment. Years of inappropriate diagnosis and ineffective therapy take a heavy toll on these patients. Some have psychologic problems to the point that no treatment, no matter how well indicated, will make them well. Some have had symptoms so long that there is permanent neurologic damage. Each patient presents his or her own diagnostic challenge. Solving the problem and providing effective therapy can be rewarding for doctor and patient.     

Superior thoracic outlet syndrome

The authors discuss Superior Thoracic Outlet Syndrome (STOS), which is characterized by aspecific symptomatology. However, some tests may be used to reveal the specificity of the disease. In the past, treatment was often followed by recurrence of the disease. In the last ten years, the Roos operation has been used with a high success rate.     

Arterial thoracic outlet syndrome

Arterial vascular complications resulting from thoracic outlet compression, although rare, can be substantial and potentially limb threatening. Bony abnormalities such as cervical ribs can lead to chronic trauma to the subclavian artery. Early on, the clinical symptoms can be subtle and confusing, causing potential delay in diagnosis.     

Recurrent thoracic outlet syndrome

In the author's experience, the rate of recurrence is lower (5%-10%) when a combined procedure (transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy) is performed as the primary operation. The author strongly believes this combined procedure accomplishes an excellent decompression of the thoracic outlet area and decreases the rate of recurrence and reoperation. In addition, spontaneous recurrence most likely is caused when scar tissue gradually builds up in the surgical area. For this reason, as mentioned previously, the author instructs and encourages patients to start postoperative exercises the day after surgery and to continue these exercises for at least 6 months and preferably 1 year to improve brachial plexus and subclavian vessel gliding and to minimize the harmful effects of scar tissue.     

Diagnosis of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a nonspecific label. When employing it, one should define the type of TOS as arterial TOS, venous TOS, or neurogenic TOS. Each type has different symptoms and physical findings by which the three types can easily be identified. Neurogenic TOS (NTOS) is by far the most common, comprising well over 90% of all TOS patients. Arterial TOS is the least common accounting for no more than 1%. Many patients are erroneously diagnosed as "vascular" TOS, a nonspecific misnomer, whereas they really have NTOS. The Adson Test of noting a radial pulse deficit in provocative positions has been shown to be of no clinical value and should not be relied upon to make the diagnosis of any of the three types. The test is normal in most patients with NTOS and at the same time can be positive in many control volunteers. Arterial TOS is caused by emboli arising from subclavian artery stenosis or aneurysms. Symptoms are those of arterial ischemia and x-rays almost always disclose a cervical rib or anomalous first rib. Venous TOS presents with arm swelling, cyanosis, and pain due to subclavian vein obstruction, with or without thrombosis. Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesia, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds.     

Management of thoracic outlet syndrome

Summary The experience with transaxillary first-rib resection and scalenotomy reported herein shows these to be safe and effective treatments for patients with thoracic outlet syndrome (TOS). The former operation usually offers the best possibility for complete resection of the first rib and all anomalous congenital bands, and is curative in most cases, regardless of the mechanism of the compression. Scalenotomy, or Powers' operation, is also helpful, in particular for cases of TOS with a vertebral arterial insufficiency. Accurate diagnosis of TOS and selection for surgery after a detailed history and proper physical examination will result in gratifying relief of symptoms in almost all patients with TOS.     

Management of thoracic outlet syndrome

The experience with transaxillary first-rib resection and scalenotomy reported herein shows these to be safe and effective treatments for patients with thoracic outlet syndrome (TOS). The former operation usually offers the best possibility for complete resection of the first rib and all anomalous congenital bands, and is curative in most cases, regardless of the mechanism of the compression. Scalenotomy, or Powers' operation, is also helpful, in particular for cases of TOS with a vertebral arterial insufficiency. Accurate diagnosis of TOS and selection for surgery after a detailed history and proper physical examination will result in gratifying relief of symptoms in almost all patients with TOS.     

Epidemiology of thoracic outlet syndrome

Thoracic outlet syndrome (TOS) describes a complex disease process with three anatomic variations each with their own individual characteristics. Understanding the prevalence, diagnosis, and treatment of TOS is challenging for many providers. For this reason, the establishment of comprehensive care models and expert leadership by dedicated vascular surgeons with TOS experience has been invaluable.     

History of thoracic outlet syndrome

Thoracic outlet syndrome (TOS), a condition in which neurovascular structures in the thoracic outlet region are compressed, can be caused by anatomical abnormalities or acquired changes in the soft tissues and bony structures in the region. The brachial plexus is the most frequently affected structure. TOS is one of the most difficult neurovascular compressions in the upper extremity to manage because of the variability of complaints and the high risk associated with surgical treatment.     

Pseudarthrosis of cervical rib: an unusual cause of thoracic outlet syndrome

Thoracic outlet syndrome is uncommon in adolescence. Cervical rib fracture is an extremely rare cause of thoracic outlet syndrome in this age group. We report an unusual case of thoracic outlet syndrome in a 14-year-old girl caused by pseudarthrosis of the cervical rib. A magnetic resonance imaging scan showed significant compression of the brachial plexus by the pseudarthrosis mass. Excision of the cervical rib through a supraclavicular approach gave excellent results in this case.     

The management of thoracic outlet syndrome in teenaged patients

While thoracic outlet syndrome (TOS) is known to afflict teenaged patients, reported data are limited to small groups or individual cases. Management of TOS in teenagers presents many issues, including performing surgery in patients whose skeletal growth may not be completed. Additionally, surgical intervention may result in loss of school time. The aim of this study was to assess our results with a large series of young TOS patients in order to provide insight toward achieving optimal care. Via a retrospective chart review, we identified all patients <20 years of age undergoing first rib resection for TOS during an 11-year period (August 1994-September 2005) at a single university hospital. History, indication, operative details, and pertinent follow-up were obtained from the records. There were 18 patients <20 who underwent first rib resection in the study period (all but one via a transaxillary approach). Ages ranged 13-19 years. Twelve patients had disabling neurogenic (NG) TOS, and six presented with Paget-Schroetter syndrome (PS). Seventy-two percent of patients were female. Most students (14/18) were forced to take a leave from school due to severity of symptoms. Eighty-five percent of female patients presented with NG TOS, whereas PS TOS affected 80% of male patients. All PS TOS patients were involved in high-intensity athletics, while 75% of NG TOS patients were student athletes. Follow-up ranged from 30 days to over 12 years. There were no significant operative complications in either group. Forty-two percent of NG patients experienced continued symptoms leading to anterior scalenectomy. All PS patients had successful lysis of their thrombotic processes. Overall, 25% of NG TOS patients also required postoperative trigger point injections. All patients eventually recovered and were able to resume academic as well as competitive athletic activities. TOS can be effectively and safely treated in the teenage years. PS responds well to standard thrombolysis and surgical decompression. NG TOS presenting in these young patients appears more likely to require extensive surgical decompression (both rib resection and total scalenectomy) in order to achieve optimal results. Given the psychosocial and academic implications of this disease, careful diagnosis and appropriate treatment are imperative.