From the Guidelines
Vascular thoracic syndrome, also known as thoracic outlet syndrome (TOS), should be managed conservatively with physical therapy and anti-inflammatory medications as the first line of treatment, with surgical intervention considered only for severe cases that do not respond to conservative measures. This approach is based on the understanding that TOS is a condition where the brachial plexus, subclavian artery, and/or subclavian vein become compressed at the superior thoracic outlet, leading to symptoms such as pain, numbness, and weakness in the affected arm and hand 1. The costoclavicular triangle, interscalene triangle, and pectoralis minor space are the three distinct spaces that can be implicated in TOS, with narrowing of each space resulting in slightly different presentations due to differing severity of impingement on the transiting neurovascular structures.
Key Considerations for Management
- Physical therapy focusing on stretching and strengthening exercises for the shoulder muscles can help improve posture and create more space in the thoracic outlet, thereby reducing compression on the neurovascular structures.
- Anti-inflammatory medications like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) can help manage pain and inflammation associated with TOS.
- Patients should avoid activities that worsen symptoms, such as carrying heavy bags on the affected side or positions that require arms to be held overhead for extended periods.
- Surgical intervention, such as thoracic outlet decompression, may be necessary for severe cases that do not respond to conservative measures, and involves removing the first rib or any cervical ribs to relieve pressure on the compressed neurovascular structures.
Importance of Accurate Diagnosis
Accurate diagnosis of TOS is crucial for effective management, and understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes are important in choosing and interpreting radiological imaging, which may be performed to help diagnose TOS and plan for intervention 1. Consultation with a radiologist may be useful at the time of examination ordering to optimize the study for the prevailing clinical symptom.
From the Research
Definition and Classification of Vascular Thoracic Syndrome
- Vascular thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest 2.
- TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively 2.
- Venous thoracic outlet syndrome is a complex but rare disease that often can have excellent outcomes if quickly recognized and treated 3.
Diagnosis and Treatment of Vascular Thoracic Syndrome
- Modern diagnosis is made with a combination of clinical exam, appropriate non-invasive imaging, and, finally, contrast venography, which can be both diagnostic and therapeutic 3.
- Contrast-enhanced three-dimensional (3D) magnetic resonance angiography (MRA) with equilibrium phase using provocative arm positioning is the optimal examination to determine presence, degree of vascular compression, and complications of vascular thoracic outlet syndrome 4.
- Combining venography and endovascular venous intervention with surgical decompression in managing patients with clinically suspected venous TOS is safe and effective 5.
- Non-invasive methods both for the diagnosis and the treatment of vascular TOS are gaining ground, and medicine is slowly putting aside the previous invasive gold-standard methods, to be used only in the most urgent situations 6.
Importance of Prompt Diagnosis and Treatment
- One of the most important predictors of outcome is the initiation of treatment within 14 days of symptoms 3.
- Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief 2.
- Postdecompression venoplasty appears to be highly effective, with a low rate of symptom recurrence 5.