Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome

Abstract

ObjectiveThoracic outlet syndrome (TOS) should be considered of arterial origin only if patients have clinical symptoms that are the result of documented symptomatic ischemia. Simultaneous recording of inflow impairment and forearm ischemia in patients with suspected TOS has never been reported to date. We hypothesized that ischemia would occur in cases of severely impaired inflow, resulting in a non-linear relationship between changes in pulse amplitude (PA) and the estimation of ischemia during provocative attitudinal upper limb positioning.DesignProspective single center interventional study.MaterialFifty-five patients with suspected thoracic outlet syndrome.MethodsWe measured the minimal decrease from rest of transcutaneous oximetry pressure (DROPm) as an estimation of oxygen deficit and arterial pulse photo-plethysmography to measure pulse amplitude changes from rest (PA-change) on both arms during the candlestick phase of a “Ca + Pra” maneuver. “Ca + Pra” is a modified Roos test allowing the estimation of maximal PA-change during the “Pra” phase. We compared the DROPm values between deciles of PA-changes with ANOVA. We then analyzed the relationship between mean PA-change and mean DROPm of each decile with linear and second-degree polynomial (non-linear) models. Results are reported as median [25/75 centiles]. Statistical significance was p < 0.05.ResultsDROPm values ranged −11.5 [−22.9/−7.2] and − 12.3 [−23.3/−7.4] mmHg and PA-change ranged 36.4 [4.6/63.8]% and 38.4 [−2.0/62.1]% in the right and left forearms, respectively. The coefficient of determination between median DROPm and median PA-change was r2 = 0.922 with a second-degree polynomial fitting, but only r2 = 0.847 with a linear approach.ConclusionOxygen availability was decreased in cases of severe but not moderate attitudinal inflow impairments. Undertaking simultaneous A-PPG and forearm oximetry during the “Ca + Pra” maneuver is an interesting approach for providing objective proof of ischemia in patients with symptoms of TOS suspected of arterial origin.

Upper arm versus forearm transcutaneous oximetry during upper limb abduction in patients with suspected thoracic outlet syndrome

“…Nevertheless, Doppler (as would pulse plethysmography) provides evidence for flow impairment but not for the presence of ischemia itself. Indeed, even arterial positional non-occlusive compression can provide sufficient perfusion to result in no significant oxygen delivery deficit and cause no arterial ischemia ( Hersant et al, 2022 ). There are potential advantages of using TcpO2 to diagnose an arterial compression and argue for arterial TOS.…”

“…Maximal amplitude of the decrease in TcpO2 can be expressed as the "minimal decrease from rest of oxygen pressure" (DROPm) index (Henni et al, 2019;Abraham et al, 2020). We also previously showed that positional compression of the subclavian artery does not necessarily result in arterial ischemia (Hersant et al, 2022).…”