What is the management for arterial Thoracic Outlet Syndrome (TOS)?

Management of Arterial Thoracic Outlet Syndrome

All patients with arterial TOS require surgical thoracic outlet decompression with first rib resection and anterior scalenectomy, and most (approximately 69%) will also need subclavian artery reconstruction. 1, 2, 3

Immediate Management Based on Presentation

Acute Limb Ischemia (29% of cases)

• Urgent revascularization is required first through either catheter-directed thrombolysis (CDT) or brachial artery thromboembolectomy (BAT) to restore blood flow 3
• Critical timing issue: Delayed thoracic outlet decompression after initial revascularization carries a 33% cumulative risk of recurrent thromboembolism by 90 days 3
• Proceed to definitive thoracic outlet decompression as soon as medically feasible, typically within 23 days (median) after initial revascularization 3
• Consider therapeutic anticoagulation during the interval period, though this does not eliminate recurrent embolic risk 3

Chronic Presentation (69% of cases)

• Symptoms include arm claudication, pallor, cool extremity, or chronic ischemic findings 4, 3
• Proceed directly to surgical planning after diagnostic confirmation 2

Diagnostic Confirmation Required Before Surgery

Obtain chest radiography first to identify cervical ribs, first rib anomalies, or other bony abnormalities causing the compression 1, 5

Perform CTA with IV contrast in both neutral and elevated arm positions to assess:

• Arterial compression, stenosis, or occlusion 1, 5
• Presence of subclavian artery aneurysm 6, 3
• Mural thrombus or intimal damage 2
• Distal emboli 5
• Use sagittal reformations, not just axial slices, as axial views underestimate stenosis in 43% of cases versus only 10% with sagittal views 7, 5

Definitive Surgical Management

Always Required

Thoracic outlet decompression must be performed in all cases, which includes: 1, 2, 3, 8

• First rib resection 2, 3, 8
• Anterior scalenectomy 8
• Resection of any cervical ribs or rudimentary ribs 8
• Removal of any fibromuscular bands causing compression 6

Subclavian Artery Reconstruction (Required in 69% of Cases)

Arterial reconstruction is warranted when imaging or intraoperative findings reveal: 2, 3

• Intimal damage to the artery 2
• Mural thrombus 2
• Aneurysmal dilation 6, 2
• Significant stenosis or occlusion 6, 3

Reconstruction options include: 6

• Bypass grafting (most common) 6
• Direct arterial repair 6

Avoid endovascular stenting due to ongoing external compression in the thoracic outlet, which leads to stent failure 2

Additional Procedures for Distal Embolization

When patients present with hand or finger ischemia from distal emboli: 2, 3

• Perform embolectomy of affected vessels 2
• Consider lytic catheter placement 2
• Initiate therapeutic anticoagulation 2
• Warning: Despite these measures, finger amputation may still be required in some cases with severe distal embolization 2

Conservative Management Has No Role

Unlike neurogenic TOS, physical therapy and conservative measures are not appropriate for arterial TOS because patients present with vascular pathology (thrombosis, aneurysm, stenosis) requiring surgical correction 4, 2

Outcomes and Prognostic Factors

Expected outcomes after appropriate surgical management: 6, 3

• Subclavian artery/graft primary patency of 87% at 5 years 3
• Secondary patency of 90% at 5 years 3
• Most patients (82% in one series) return to work 6

Poor prognostic indicators for chronic symptoms: 3

• Preoperative forearm or hand pain predicts persistent chronic pain (p=0.04) 3
• Brachial artery occlusion at presentation predicts both chronic pain (p=0.03) and persistent weakness (p=0.02) 3
• These patients have 14% risk of chronic upper extremity pain and 14% risk of persistent weakness despite successful surgery 3

Critical Pitfalls to Avoid

Do not delay thoracic outlet decompression in patients presenting with acute limb ischemia - each week of delay increases recurrent thromboembolism risk, with 8% risk by 14 days, 17% by 30 days, and 33% by 90 days 3

Do not perform arterial reconstruction without thoracic outlet decompression - the external compression will cause graft or repair failure 2, 8

Do not use endovascular stenting as the ongoing external compression causes stent failure 2

Do not miss the diagnosis - arterial TOS often goes unrecognized until acute presentation, and early accurate diagnosis is necessary to reduce morbidity 3