Vascular Thoracic Outlet Syndrome Research Articles

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review.

Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome. Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS. In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

Anatomy and Pathogenesis of Vascular Thoracic Outlet Syndrome.

The current literature review article describes the anatomy and pathogenesis of the vascular nature of thoracic outlet syndrome (TOS), as well as gathers the latest and most important information concerning its diagnostic methods and treatment. This syndrome's subcategory includes the venous and the arterial. Data for this review was accumulated through the PubMed database in which only scientific studies published in the last decade (2012-2022) were searched. PubMed offered 347 results, of which 23 were judged suitable and used. Non-invasive methods both for the diagnosis and the treatment of vascular TOS are gaining ground. Medicine, at this point, finds itself on the verge of slowly putting aside the previous invasive gold-standard methods, to be used only in the most urgent situations. The vascular thoracic outlet condition is a rare form of TOS but is also the most trouble-causing one and the deadliest. Fortunately, it can be more efficiently managed because of the current medical innovations. However, further research is needed to establish their already confirmed effectiveness, so they can be even more widely trusted and used.

Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis

BackgroundThe subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle. PurposeTo provide comprehensive gross anatomy description of the variant “subclavius posticus muscle” and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression. Basic proceduresA scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed. Main findingsThe scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all. Principal conclusionsThe subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.

True Neurogenic Thoracic Outlet Syndrome with Elongated C7 Transverse Processes in a Hemiplegic Patient: A Case Report

Thoracic outlet syndrome (TOS) is caused by the compression of neurovascular structures in the thoracic cage. TOS can be classified into neurogenic TOS (NTOS) and vascular TOS. Congenital anomalies, such as cervical ribs and elongated C7 transverse processes, may be the cause of NTOS. NTOS can be subcategorized as either disputed NTOS or true NTOS. True NTOS, a very rare disease with a prevalence of about one in a million, is diagnosed by the weakness and atrophy of T1-innervated intrinsic muscles of the hand and corresponding electrodiagnostic abnormalities. We report a case of a 42-year-old patient, who presented with a 5-year history of clumsiness and 1 1-year history of weakness and atrophy in her right hand. The patient was diagnosed with true NTOS during comprehensive rehabilitation, which she received for left hemiplegia due to intracranial hemorrhage. Elongated bilateral C7 transverse processes were found on a radiological evaluation. True NTOS is often overlooked or mistaken for carpal tunnel syndrome, thus delaying the diagnosis and inevitably worsening outcomes. Therefore, an electrodiagnostic study is crucial for detecting true NTOS, rather than typical physical examinations such as the Roos stress test and Adson’s test.

Point-of-Care Ultrasound in the Diagnosis of Venous Thoracic Outlet Syndrome

BackgroundClinicians trained in point-of-care ultrasound (POCUS) use the tool to enhance diagnostic capabilities at the bedside, often excluding or diagnosing conditions that are suspected based on the history and physical examination. Thoracic outlet syndrome (TOS) involves compression of arteries and nerves between the clavicle and first rib causing pain and paresthesia in the affected limbs. To our knowledge, use of POCUS to diagnose TOS in the literature has not been described. Case ReportA 46-year-old man presented with left upper extremity (LUE) edema, pain, and paresthesia, which was progressive over 3 weeks. Examination of the LUE revealed diffuse swelling without erythema and a left radial pulse present on Doppler only. A subsequent POCUS examination of the LUE was performed to exclude a deep vein thrombosis, and enlarged and turbulent veins distal to the internal jugular vein were found, which suggested venous compression external to the veins. Additional imaging confirmed narrowing of the subclavian vein and a diagnosis of venous thoracic outlet syndrome (vTOS) was made. Why Should an Emergency Physician Be Aware of This?Failure to promptly diagnose and treat TOS can lead to long-term chronic upper extremity pain and even permanent disability. Diagnosis of vascular TOS is often made using computed tomography to identify impinged vessels, although color Doppler sonography can be an excellent choice for initial imaging in patients with suspected vTOS. Although POCUS is being used increasingly as a diagnostic tool and for procedural guidance, our case represents a novel application of POCUS in the diagnosis of vTOS.

Thoracic outlet syndrome: a review

Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.

Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity, specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity, specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%, respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone. The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.

Vascular thoracic outlet syndrome: Registry of 30-years of patient's outcomes at King Saud University Medical City, Riyadh, Saudi Arabia.

To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS). This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months). A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases. Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

Combined nerve and vascular ultrasound in thoracic outlet syndrome: A sensitive method in identifying the site of neurovascular compression.

We investigated the diagnostic utility of combined nerve and vascular ultrasound in thoracic outlet syndrome (TOS) in a retrospective cohort study on two sites, involving 167 consecutive patients with the clinical symptoms suggestive of neurogenic and/or vascular TOS, and an age- and sex-matched control group. All patients and control subjects underwent nerve ultrasound of the supraclavicular brachial plexus to look for fibromuscular anomalies / compression of the brachial plexus in the scalenic region, and vascular ultrasound of the infraclavicular subclavian artery with the arm in neutral and abducted position, serving as an indicator for costoclavicular compression of the neurovascular bundle. Based on clinical symptoms, neurogenic TOS (81%) was the most frequent type of TOS, followed by combined neurogenic and arterial TOS (8%). The frequency of abnormal nerve and/or vascular ultrasound findings differed significantly from the control group (P<0.00001). The pooled sensitivity was 48% for nerve ultrasound, 85% for vascular ultrasound, and 94% when combined. Among the findings, the fibromuscular ‘wedge-sickle sign’, indicating compression of the lower trunk in the scalenic region by a congenital fibromuscular anomaly (e.g. Roos ligaments), showed the highest specificity (100%). A bony ‘wedge-sickle sign’ was also delineated, where lower trunk compression is caused by the neck of the 1st rib. As implied by the higher sensitivity of vascular ultrasound, the most common site of compression was the costoclavicular space, but multilevel compression was also frequently observed. In summary, combined nerve and vascular ultrasound is a sensitive and reliable method to support the diagnosis of TOS. It can also identify the site(s) of compression, with obvious therapeutic consequences.

Thoracic Outlet Syndrome in Major League Baseball Pitchers: Return to Sport and Performance Metrics After Rib Resection.

Background:Thoracic outlet syndrome (TOS) is a rare injury that affects Major League Baseball (MLB) pitchers and is often corrected with surgical resection of the first rib. There are limited return-to-play (RTP) data for this surgery in MLB pitchers.Hypothesis:It was hypothesized that MLB pitchers who undergo first rib resection for TOS will show (1) a high rate of RTP, (2) no difference in postoperative career length compared with controls, (3) no difference in pre- and postoperative performance, and (4) no difference in postoperative performance compared with controls.Study Design:Cohort study; Level of evidence, 3.Methods:This retrospective cohort study evaluated MLB pitchers with neurogenic or vascular TOS who underwent rib resection surgery between January 1, 2001, and December 31, 2019. Players were identified through public injury reports from press releases, the MLB website, MLB team injury reports, and blogs. A demographics- and performance-matched control group was generated for comparison. Each player in the control group was given an index year that corresponded to the surgery year of the case group. Performance data included innings pitched (IP), games played (GP), earned run average (ERA), complete GP, shutouts, saves, hits, runs, home runs (HR), walks, strikeouts (K), walks plus hits per IP (WHIP), and earned runs (ER).Results:We identified 26 MLB pitchers who underwent rib resection for neurogenic or vascular TOS; 21 players (81%) had a successful RTP. Pitchers were 30 ± 3.6 years old at the time of surgery and had played 6.2 ± 3.5 seasons before undergoing surgery. Average postoperative career length was 3.1 ± 2.0 seasons, with an average time from surgery to RTP being 10 ± 4.7 months. Pitchers who RTP showed no significant differences in performance metrics compared with controls. Players pitch 0.94 (P < .05) more IP/GP in the season directly following RTP compared with the season before surgical intervention.Conclusion:MLB pitchers undergoing rib resection for TOS demonstrated (1) high RTP rates following rib resection, (2) no difference in postoperative career length compared with controls, (3) improvement in postoperative performance, and (4) no difference in postoperative performance compared with controls.

The role of congenital malformations of the thoracic outlet in the development of the syndrome.

Thoracic outlet syndrome (TOS) represents a clinical condition caused by compression of the neurovascular structures that cross the thoracic outlet. TOS can be classified in: 1) neurogenic TOS (NTOS), 2) venous TOS (VTOS), 3) arterial TOS (ATOS). Many different causes can determine the syndrome: congenital malformations, traumas, and functional impairments. This manuscript reviews how the congenital malformations play an important role in adult age; however, TOS also affects patients of all ages. Radiological imaging like X-ray (radiography), magnetic resonance and computed tomography can provide useful information to assess TOS causes and decide a potential surgery. 79% of the patients included in the first two stages of nerve, artery, vein (NAV) staging experienced excellent results with kinesiotherapy; whereas patients included in the third and fourth stage of NAV staging were subject to surgery. The treatment of acute forms of TOS involves thrombolysis and anticoagulant therapy; surgery is appropriate for true NTOS, vascular TOS and in some cases when conservative treatment fails.

Vascular Thoracic Outlet Syndrome in 3 Pediatric Patients

<h3>Introduction</h3> Thoracic outlet syndrome (TOS) may lead to vascular complication and represents the minority of TOS case in adults. However in the pediatric population TOS vascular complications are morefrequent. Management is commonly described in adult populations, but in children and teenagersdiagnosis and treatment is not as well defined and presents different challenges than in adults. We describe three cases of vascular TOS in a pediatric population and review of the literature.Case <h3>Reports</h3> The first patient is a 14-year-old girl who was a competitive swimmer presented with left arm pain and swelling for several months worse the last 4 weeks. Venogram¹ revealed complete occlusion of the left subclavian and axillary veins and following a course of lytic therapy a 50%axillary vein stenosis with complete occlusion with left arm abduction was noted². She underwent left first rib resection and resumed competitive swimming. Follow up venous duplexshowed no venous compression with the arm adducted and with full abduction.Figure 1.Figure 1Figure 2.Figure 2Figure 3.Figure 3Figure 4.Figure 4Figure 5.Figure 5Figure 6.Figure 6 The second patient is a 13-year-old female who was also a competitive swimmer but who coincidentally had mild scoliosis³. She presented after a 2 day history of left arm swelling. Venogram revealed left subclavian and axillary vein thrombosis and she also underwent a course of lytic therapy. Post-therapy imaging showed an occlusion of the left axillary vein with abduction similar to the first patient⁴ and so she also underwent left first rib resection. Follow up venous duplex showed no venous compression. The third patient is a 16-year-old male who had been weight training presented with sudden onset of left arm pain 1 week prior to admission. Arteriogram revealed occluded left axillary artery⁵. Following combined lytic therapy and open left brachial artery thrombectomy repeat arteriogram revealed a patent left axillary artery⁶ and complete occlusion with left arm abduction. He underwent left first rib resection. At 2 months of follow up he was asymptomatic with normal axillary duplex with the arm adducted and with abduction. <h3>Discussion</h3> Vascular complications of TOS in the pediatric population can be managed in a similar fashionas adults. Return to premorbid activities can be expected. Pediatric patients can present some challenges with timely diagnosis and treatment.

Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment?

In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71–270 min (median 128.5 min, SD +/− 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/− 2.1 days). Stent grafting was performed 5–35 days (mean 14.8 days, SD +/− 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.

Specialty Mediated 30-Day Complications in First Rib Resection for Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) takes on heterogenous upper extremity manifestations depending on whether the artery, vein or brachial plexus is primarily compressed. As a result of these variable vascular and neurogenic symptoms, these patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work we examine the association of surgeon specialty with short-term outcomes following first rib resection (FRRS) for TOS. Using the American College of Surgeons National Surgical Quality Improvement Program database, 3,070 patients were identified who underwent FRRS for TOS between 2006-2017. The primary outcomes of the study were 30-d complications, including postoperative hemorrhage requiring transfusion, wound complications, pneumothorax and deep venous thrombosis. Arterial, venous, and neurogenic TOS were distinguished with ICD-9 and 10 codes while patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and ICD data. Most FRRS were performed by vascular surgeons (87.9%), general (6.9%) and thoracic surgeons (4.4%). The relative distribution of vascular TOS between the specialties was not significantly different, with non-vascular surgeons performing an equivalent amount of FRRS for arterial (1.1% versus 2.4%) and venous TOS (8.6% versus 9.1%, both P> 0.05). Patients who underwent FRRS with non-vascular surgeons experienced more frequent perioperative transfusions (3.2% versus 1.2%, P=0.001) and wound infections (1.9% versus 0.8%, P= 0.04). On multivariable regression, patients undergoing FRRS for venous TOS were more likely to require blood transfusion (odds ratios:3.63, 95% CI 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRRS had a 40% longer operative time (incidence rate ratios:1.42, 95% CI 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratios:9.87, 95% CI 2.28-42.68). The significantly increased operative times and transfusion requirements associated with specialties who uncommonly perform FRRS suggest the role of surgeon experience and volume in this procedure may play more of a role than specialty training. These data also suggest that vascular TOS carries unique risks that should be kept in mind when performing FRRS.

The treatment of the atrophic clavicular nonunion by double-plate fixation with autogenous cancellous bone graft: a prospective study

BackgroundThe objective of this study is to assess prospectively the effectiveness of double-plate fixation combined with autogenous cancellous bone graft in the treatment for the atrophic clavicular nonunion.MethodsBetween February 2013 and November 2017, a total of 12 patients with atrophic clavicular nonunion (mean age, 40.4 ± 9.0 years, range, 27–60 years) were treated by double-plate fixation with autogenous cancellous bone graft in our institute. The Constant Score System was used to evaluate the preoperative and final outcomes. The Short Form-36 (SF-36) outcome questionnaire was used to assess the final clinical results.ResultsAll patients were followed-up, with the average follow-up of 34.7 ± 6.7 months (range, 24–48 months). The healing rate was 100% in our study. The mean time of bony union was 9 weeks (range, 8–10 weeks). One patient had a postoperative superficial infection, and the patient was cured by oral antibiotics and wound dressing. No implant-related complications (plate-screw loosening or breakage) were observed postoperatively. No vascular injury, neural impairment, or thoracic outlet syndrome was discovered preoperatively or postoperatively. There is a statistical significance between the preoperative and the postoperative constant scores (P < 0.05). All the patients were satisfied with their final clinical results by SF-36 outcome questionnaire. Average scores of the physical function and bodily pain components of the SF-36 were 94.2 ± 7.3 and 92.5 ± 5.8, respectively.ConclusionOur results presented that double-plate fixation with autogenous cancellous bone graft is an effective treatment for atrophic clavicular nonunion, especially for those with a significant bone defect.

Transaxillary Approach for First Rib Resection in Combined Neurogenic and Vascular Thoracic Outlet Syndrome with Elongated C7 Transverse Process and Status Post Breast Implantation: A Case Report

Combined neurogenic and arterial Thoracic Outlet Syndrome (nTOS and aTOS) is a rare disease. First rib resection with scalenectomy is a mainstay of treatment. TOS results from pathology in the interscalene triangle. Many etiologies were described as its contributing factors, however, to the author’s knowledge, axillary breast implantation had not yet been described. In patients who have mild anatomical pathology, scar formation from axillary surgery may aggravate TOS symptoms. The author wishes to present a case of mild elongated C7 transverse process that then underwent breast implantation, subsequently developed combined nTOS and aTOS, successfully managed through transaxillay first rib resection and scalenectomy.

Thirty-year experience of transaxillary resection of first rib for thoracic outlet syndrome.

Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years. A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates. One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%). In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.

An overview of the findings of dynamic upper limbs\u2019 arterial and venous duplex in cases of vascular thoracic outlet syndrome

BackgroundTo describe the findings of the dynamic upper limb arterial and venous duplex in the assessment of vascular compression in cases of VTOS. This study was conducted on 58 patients with VTOS; they were evaluated by dynamic duplex examination.ResultsVascular compression was subdivided into a venous compression that was detected in (84.4%, n = 49), arterial compression that was seen in (1.7%, n = 1), and combined arterial and venous compression that was present in (13.7%, n = 8); bilateral compression was existing in (94.4%, n = 55), compression at the scalene triangle was seen in (1.7%, n = 1), at the costo-clavicular space was seen in (91.3%, n = 53), and at the retro-pectoral space was depicted in (8.6%, n = 5).Complicated arterial compression was detected in (1.7%, n = 1), whereas venous complications were seen in (6.8%, n = 4).ConclusionDynamic duplex ultrasound offered a simple, noninvasive, and quick technique that can help in the evaluation of the vascular thoracic outlet syndrome without exposure to ionizing radiation or contrast media administration like that in CT; nevertheless, it is done with the patient in the upright position, thus avoiding the high false-negative results associated with the supine position that is used in the CT and MRI studies.

P46 Swimmer’s thoracic outlet: it doesn’t have quite the same ring as tennis elbow!

Abstract Background We present a case that was referred and seen in our chronic pain clinic, and highlight the importance of keeping an open mind about alternative diagnoses when reviewing these patients. Methods Please refer to the results section. Results A 12 year-old girl was referred with right sided neck and shoulder pain associated with occasional pins and needles. The patient was a competitive swimmer, training and competing five times a week at her peak. She did not have a history of mottling or colour change, and clinically she had full range of motion of her joints and no neurological deficit. On repeated assessments, she had reproducible pain on horizontal flexion and reduced muscle bulk of the right shoulder, although power was preserved. Functionally the patient had to reduce her participation in swimming due to pain, and found it difficult to carry or lift things, brush or wash her hair, or write for extended periods of time. Imaging with shoulder X-ray and shoulder and cervical spine MRI did not reveal a cause, and she did not have an anatomical variation such as a thoracic rib. Due to the reproducibility on swimming, an ultrasound looking at the insertion of the biceps insertion during dynamic movements was arranged and was also normal with no subluxation noted. As she failed to improve with chronic pain education, chronic pain approach to physiotherapy sessions and graded reintroduction of swimming, ultrasound angiology was arranged. This showed minor disease in the right subclavian, axillary, brachial, radial and ulnar arteries, with significant reduction in right brachial arterial flow with the patient supine, right arm in horizontal flexion and contralateral head turn. This suggested arterial thoracic outlet syndrome (TOS). All other positions resulted in no significant difference in arterial flow. TOS is traditionally broken into two categories – neurogenic and vascular, the latter can be broken down further into arterial or venous. While in adults, the vast majority (90-95%) present as neurogenic, in the paediatric population there is a higher proportion of vascular cases. This has implications, as vascular TOS can be complicated by vessel disease and thrombus formation. There are a number of case reports in which management is reported as decompression of the thoracic outlet with partial first rib resection, with or without scalene muscle resection. Consideration of hypercoagulable states is also warranted. We have referred our patient to the vascular team for an urgent review and await their assessment and feedback about management. Conclusion A proportion of patients managed with chronic pain syndrome will have an alternative explanation for their pain. In particular, if a patient has focal pain or pain that is reproducible on a particular movement or activity, consider alternate diagnoses. Conflicts of Interest The authors declare no conflicts of interest.

Progress in diagnosis and therapy of thoracic outlet syndrome

Thoracic outlet syndrome(TOS) are constellation of symptoms caused by compression of the neurovascular bundle including the brachial plexus, the subclavian artery and the subclavian vein at the thoracic outlet region. It includes neurogenic TOS, venus TOS, arterial TOS, and neurogenic TOS is the most common type. TOS has varied manifestations and lack of confirmatory testing, therefore, the diagnosis should be conbination with thorough history, physical examination and associated supplementary examinations. Conservative and surgical treatment can be choosed for TOS and the outcomes are generally good. Conservative management is the initial treatment strategy for neurogenic TOS. In cases of symptomatic vascular TOS and neurovascular TOS, which has been failed by conservative treatment, surgery should be considered more promptly.