Vascular Thoracic Outlet Syndrome
Figure 1. Thoracic Outlet (Jones, 2019)
Figure 2. Illustration of vascular thoracic outlet syndrome (courtesy of semthorcardiovascsurg.com)
Figure 3. Venous TOS algorithm (Jones, 2019)
Arterial TOS is approached in a similar manner as venous TOS with management being dependent on the nature and severity of arterial complications. Asymptomatic patients without evidence of arterial degeneration may be managed nonsurgically. It is reasonable to follow these patients serially with imaging with arterial ultrasound every 6 months. No definitive guidelines exist for this. Surgical treatment is required with patients presenting with evidence of arterial complications, such as intimal damage, mural thrombus, embolization, poststenotic dilatation, or aneurysm formation. Decompression is performed with resection of cervical or first ribs, fibrous bands, scalenectomy and any other associated anomalies. As with venous TOS, many providers resect the first rib to prevent recurrence of symptoms. There is debate whether a scalenectomy alone is as effective as first rib resection (14,15). THe next step in management for these patients is arterial resection of any source of arterial embolus such as a subclavian artery aneursym or luminal stenosis with intimal damage. This is done to prevent ischemic complications of the upper extremity. Digital revascularization is the last step with vascular reconstruction in the form of primary anastomosis, interposition graft, or axillary-brachial bypass depending on extent of the subclavian artery resection. If distal embolus is presents, intraarterial thrombolysis or thromboembolectomy may be used in conjunction with arterial reconstruction to improve outflow of the limb (16).