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Review
. 2017 Jun 10;7(2):34.
doi: 10.3390/diagnostics7020034.

Vascular TOS-Creating a Protocol and Sticking to It

Meena Archie  1 , David Rigberg  2
Affiliations
Review

Vascular TOS-Creating a Protocol and Sticking to It

Meena Archie et al. Diagnostics (Basel). .

Abstract

Thoracic Outlet Syndrome (TOS) describes a set of disorders that arise from compression of the neurovascular structures that exit the thorax and enter the upper extremity. This can present as one of three subtypes: neurogenic, venous, or arterial. The objective of this section is to outline our current practice at a single, high-volume institution for venous and arterial TOS. VTOS: Patients who present within two weeks of acute deep vein thrombosis (DVT) are treated with anticoagulation, venography, and thrombolysis. Those who present later are treated with a transaxillary first rib resection, then a two-week post-operative venoplasty. All patients are anticoagulated for 2 weeks after the post-operative venogram. Those with recurrent thrombosis or residual subclavian vein stenosis undergo repeat thrombolysis or venoplasty, respectively. ATOS: In patients with acute limb ischemia, we proceed with thrombolysis or open thrombectomy if there is evidence of prolonged ischemia. We then perform a staged transaxillary first rib resection followed by reconstruction of the subclavian artery. Patients who present with claudication undergo routine arterial duplex and CT angiogram to determine the pathology of the subclavian artery. They then undergo decompression and subclavian artery repair in a similar staged manner.

Keywords: arterial TOS (ATOS); thoracic outlet syndrome; thoracic outlet syndrome (TOS); vascular TOS (VTOS).

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure A1
Figure A1
VTOS.
Figure A2
Figure A2
ATOS.
Figure 1
Figure 1
Venogram of a Paget-Schroetter patient in the stress position demonstrating significant stenosis of the right subclavian vein.
Figure 2
Figure 2
Venogram demonstrating a right subclavian vein that is nearly occluded while in stress position.
Figure 3
Figure 3
Nearly occluded right subclavian vein in stress position as demonstrated by IVUS.
Figure 4
Figure 4
Occlusion of the right subclavian vein in stress position as demonstrated by IVUS.
Figure 5
Figure 5
Arterial thoracic outlet syndrome (ATOS) patient with metal plate and screws after a prior clavicular fracture—the screws are abutting the thoracic outlet.
Figure 6
Figure 6
CT angiogram demonstrating a screw abutting the thoracic outlet in an ATOS patient with a subclavian artery aneurysm.
Figure 7
Figure 7
Left subclavian arteriography demonstrating a thrombosed brachial artery at the mid-humeral level and extensive collateralization proximally.
Figure 8
Figure 8
Left subclavian arteriography in an ATOS patient in stress position demonstrating a totally occluded subclavian artery.
Figure 9
Figure 9
Distal left arm angiography in an ATOS patient demonstrating an occluded radial artery at the origin and ulnar artery at the mid-forearm.
Figure 10
Figure 10
Angiography of the radial and ulnar arteries as well as the palmar arch and digital branches in an ATOS patient with a brachial thrombus.
Figure 11
Figure 11
Distal brachial artery thrombosis in an ATOS patient.
Figure 12
Figure 12
Excised thrombus from the brachial and radial arteries of an ATOS patient with a subclavian artery aneurysm.
See this image and copyright information in PMC

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