Searching for Lights at Dusk

Abstract

See related article on pages 151–157. Hussain et al provide a framework for the evaluation and treatment of vascular thoracic outlet syndrome (TOS). Since randomized prospective data are lacking. The optimal treatment regimen remains to be defined and many strategic differences exist. The authors provide a road map but there are many routes to the destination. The review by Hussain et al (Vascular Thoracic Outlet Syndrome, in this issue) summarizes the management of the vascular TOS in the current era. TOS can be characterized by the structure compressed: the brachial plexus in neurogenic TOS, the subclavian artery in arterial TOS (aTOS), and the subclavian vein in venous TOS (vTOS),also known as effort thrombosis or Paget-Schroetter syndrome (PSS). Neurogenic TOS is the most common form and the most difficult to diagnose and treat. The vascular forms of TOS can be objectively diagnosed with imaging studies and the response to therapy can be more predictable. The field of TOS management is plagued by a lack of strong data support relying on expert opinion and single-center series. The authors provide a concise explanation of the anatomy and etiology of TOS. The anatomical drawings are excellent adjuncts to the text. The authors did not mention some key anatomic features: fibrous bands connecting the cervical rib to the first rib that impinge on the subclavian artery or brachial plexus and the scalene musculature; each of which must be addressed to provide the best long-term outcome. The authors describe how the history and physical exam direct the evaluation; they do not sufficiently describe the key features of the exam that help with the diagnostic strategy. Plain radiography followed by duplex ultrasound and then computed tomography or magnetic resonance imaging as desired is appropriate and noninvasive. Angiography can be obtained during thrombolysis or during surgery as necessary. Also lacking is a discussion of the effect of hypercoagulable states on evaluation and management. Overall, 12% of patients with vTOS without a history of vigorous repetitive activities or anatomic are hypercoagulable. The principles of therapy of aTOS presented make an excellent basis for treatment planning. The authors address