Vascular thoracic outlet syndrome

Abstract

In the methods section of the article on vascular thoracic outlet syndrome (TOS) by Geven et al. [1], the authors point out that their indication for the diagnosis of ‘vascular TOS’ was an abnormal PPG study indicating signs of vascular compression of the subclavian artery. I question the labeling of the patients described here as having ‘vascular’ TOS. As the authors point out in their opening paragraph, there are two types of vascular TOS, arterial and venous. Because these two types are totally different from each other, the terms arterial TOS and venous TOS should be employed and the term ‘vascular’ eliminated. Venous TOS is manifested by symptoms of swelling and cyanosis, while arterial TOS by symptoms of ischemic fingers and arm claudication. Neurogenic TOS is identified by symptoms of paresthesia, weakness, and pain, not only in the upper extremity, but usually in the neck as well. Further, arterial TOS is almost always associated with a cervical rib or anomalous first rib. The symptoms of arterial TOS are usually the result of emboli from subclavian artery thrombosis, either from subclavian artery stenosis or subclavian artery aneurysm with mural thrombus. Only 6 of the 32 patients in this study had cervical ribs. Unfortunately, the authors fail to describe their patients’ symptoms which would help define the type of TOS they were treating. However, since all operations were transaxillary rib resections and none were arterial repairs, it can be assumed that none of these patients had arterial TOS and probably the large majority, if not all, of the patients had neurogenic TOS. Confusion regarding the differentiation between arterial and neurogenic TOS is common because many patients with neurogenic TOS have symptoms of coldness and color changes in their hands along with their other symptoms. These symptoms do not establish a diagnosis of arterial or vascular TOS. They are the result arteriolar vasoconstriction brought on by sympathetic nerve stimulation from compression of the sympathetic nerve fibers that accompany the C7 and C8 nerve roots [2]. Thus, these symptoms are those of neurogenic TOS