Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome.

Jeanne Hersant,Pierre Abraham,Samir Henni,Mathieu Feuilloy,Pierre Ramondou,Simon Lecoq,Xavier Papon

doi:10.3389/fphys.2022.726315

Abstract

ObjectiveThoracic outlet syndrome (TOS) should be considered of arterial origin only if patients have clinical symptoms that are the result of documented symptomatic ischemia. Simultaneous recording of inflow impairment and forearm ischemia in patients with suspected TOS has never been reported to date. We hypothesized that ischemia would occur in cases of severely impaired inflow, resulting in a non-linear relationship between changes in pulse amplitude (PA) and the estimation of ischemia during provocative attitudinal upper limb positioning.DesignProspective single center interventional study.MaterialFifty-five patients with suspected thoracic outlet syndrome.MethodsWe measured the minimal decrease from rest of transcutaneous oximetry pressure (DROPm) as an estimation of oxygen deficit and arterial pulse photo-plethysmography to measure pulse amplitude changes from rest (PA-change) on both arms during the candlestick phase of a “Ca + Pra” maneuver. “Ca + Pra” is a modified Roos test allowing the estimation of maximal PA-change during the “Pra” phase. We compared the DROPm values between deciles of PA-changes with ANOVA. We then analyzed the relationship between mean PA-change and mean DROPm of each decile with linear and second-degree polynomial (non-linear) models. Results are reported as median [25/75 centiles]. Statistical significance was p < 0.05.ResultsDROPm values ranged −11.5 [−22.9/−7.2] and − 12.3 [−23.3/−7.4] mmHg and PA-change ranged 36.4 [4.6/63.8]% and 38.4 [−2.0/62.1]% in the right and left forearms, respectively. The coefficient of determination between median DROPm and median PA-change was r2 = 0.922 with a second-degree polynomial fitting, but only r2 = 0.847 with a linear approach.ConclusionOxygen availability was decreased in cases of severe but not moderate attitudinal inflow impairments. Undertaking simultaneous A-PPG and forearm oximetry during the “Ca + Pra” maneuver is an interesting approach for providing objective proof of ischemia in patients with symptoms of TOS suspected of arterial origin.

Highlights

MATERIALS AND METHODS asymptomatic compression of the neuro-vascular bundle during arm movement is found in many apparently healthy subjects, thoracic outlet syndrome (TOS) is considered as a relatively rare disease (Demondion et al, 2006; Burt, 2018; Illig, 2018)
To the best of our knowledge, this is the first report of simultaneous recordings of PtcO2 and arterial photo-plethysmography (A-PPG), revealing a non-linear relationship between inflow changes and oxygen availability in patients with suspected TOS
This result underlines the fact that various degrees of positional arterial compressions may occur, and that defining whether an arterial compression occurs during positional tests should probably not result in a binary “Yes/No” response

Summary

Introduction

MATERIALS AND METHODS asymptomatic compression of the neuro-vascular bundle during arm movement is found in many apparently healthy subjects, thoracic outlet syndrome (TOS) is considered as a relatively rare disease (Demondion et al, 2006; Burt, 2018; Illig, 2018). According to the standards of the Society for Vascular Surgery, TOS should be considered of arterial origin only if patients have “clinical symptoms due to documented symptomatic ischemia or objective subclavian artery damage caused by compression at the level of the first rib or other related anomalous bone structures” (Illig et al, 2016). Documenting upper limb ischemia is important in confirming the arterial origin of attitudinal symptoms. Attitudinal compression can result in either incomplete (stenosis) or complete (occlusion) compression of the sub-clavicular artery, and, as a result of these, in different degrees of inflow impairment. Digital arterial photo-plethysmography (A-PPG) can be used to estimate inflow changes during attitudinal maneuvers but the changes in pulse amplitude that define inflow impairment remain debated (Gergoudis and Barnes, 1980; Geven et al, 2006; Adam et al, 2018). We recently showed that the “Ca + Pra” maneuver (a slight modification of the Roos test) allowed quantifiable measurement of the degree of inflow impairment with A-PPG (Hersant et al, 2021), while A-PPG is otherwise a semi-quantitative technique (Moco et al, 2018)

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Discussion

Conclusion