Chapter 125 - Thoracic Outlet Syndrome: Arterial

Abstract

Arterial thoracic outlet syndrome is the least common form of thoracic outlet compression but represents the strongest indication for operative intervention. Nearly all cases involve bony abnormalities leading to compression of the subclavian artery. The spectrum of arterial involvement ranges from intermittent subclavian artery compression to aneurysmal degeneration with thrombus formation. The most common presentation is hand ischemia, but fixed arterial disease such as subclavian aneurysms may occasionally be discovered as an incidental finding in asymptomatic patients. Diagnostic evaluation includes chest radiography for detection of cervical ribs and noninvasive tests such as computed tomographic angiography to evaluate the arterial circulation. Treatment consists of relieving the arterial compression, removing the source of embolus, and restoring the distal circulation. In most cases, resection of the first rib will be required in addition to removing cervical ribs or other causes of arterial compression. Patients without fixed arterial disease and those with poststenotic dilatation do not require arterial repair. However, symptomatic patients with embolizing arterial lesions and asymptomatic patients with subclavian artery aneurysms should undergo arterial resection with bypass. Scattered reports suggest that endovascular repair after thoracic outlet decompression may be appropriate in some patients, but late endograft-related complications are frequent. Patients presenting with arm or hand ischemia may require preliminary thromboembolectomy or lytic therapy prior to thoracic outlet decompression and arterial repair. Reported graft patency and functional outcomes are excellent.