Thoracic outlet syndromes

Abstract

The clinical presentation of thoracic outlet syndrome depends on which anatomic structure is compressed in the area of the thoracic outlet (eg, the axillary-subclavian artery, vein, brachial plexus, or the sympathetic nerves). The clinical syndrome may be isolated to one or a mixture of these compressed anatomic structures. Although there are multiple compressive forces, the first rib is the common denominator, and extirpation of this structure is the "gold" standard for therapy. The various syndromes are discussed in their clinical order of frequency. For severe nerve compression, whether upper or lower brachial plexus, the best surgical procedure is the transaxillary first rib resection, anterior scalenectomy, and neurovascular decompression. Axillary-subclavian vein occlusion (ie, Paget-Schroetter syndrome) is best treated with early diagnosis, intravenous thrombolysis of the clot, transaxillary first rib resection anterior scalenectomy, and resection of the costoclavicular ligament. Arterial compression, occlusion, or aneurysm may occur with or without peripheral emboli and require a supraclavicular approach with arterial ligation, endarterectomy, or bypass grafts from the supraclavicular subclavian to the infraclavicular brachial artery. Compression of the sympathetic nerves produces vasospasm, Raynaud's phenomenon, or Raynaud's disease, requiring dorsal sympathectomy as well as first rib extirpation occasionally. This may be performed through the transaxillary, supraclavicular posterior, or thoracoscopic approach. Recurrent thoracic outlet syndrome may involve any or all of the above anatomic syndromes. The surgical approach is best from the posterior, high thoracoplasty, muscle-splitting incision, performing neurolysis of the C7, C8, and T1 nerve roots and the brachial plexus as well as release of any vascular constriction.

Vascular Arterial Compression Syndromes

“…Typically, patients are treated with catheter-directed thrombolysis or surgical thromboembolectomy. Most patients with ischemic manifestations will eventually require arterial reconstruction and decompression by first rib resection [22]. Because these lesions are secondary to extrinsic mechanical compression, endovascular approaches are rarely indicated.…”

“…Thrombolytic treatment is followed by maintenance treatment with anticoagulation. It is usually recommended that patients with venous TOS with prior thrombosis undergo surgical decompression at a later stage [22].…”

A possible relationship between reliability of thoracic outlet syndrome diagnostic testing and the position of the axillary artery

“…Thoracic outlet syndrome refers to a neurological or vascular compromise of the brachial plexus of nerves or associated vasculature as these structures pass from the cervical region along the superior thoracic wall into the axilla [39,40]. The three most common anatomical locations involved with this neurovascular compromise include the interscalene triangle (between the anterior and middle scalene muscles), the costoclavicular space (between the first rib and the clavicle), and the coracopectoral tunnel (deep to the pectoralis minor muscle) [6].…”

El diagnóstico del síndrome del opérculo torácico: Mitos y realidades

“…Estas son las bases anatómicas responsables de las variadas manifestaciones sintomáticas de una compresión neural y/o arterial, y/o venosa, y/o simpática [6][7][8][9][10] . Estas compresiones pueden a su vez manifestarse, en cada caso en particular, por la presencia de diferentes síntomas y signos a consecuencias de una compresión que puede ser predominante sobre uno o varios de los componentes del paquete neurovascular.…”

“…Estas compresiones pueden a su vez manifestarse, en cada caso en particular, por la presencia de diferentes síntomas y signos a consecuencias de una compresión que puede ser predominante sobre uno o varios de los componentes del paquete neurovascular. Estos son la arteria y vena subclavias, la arteria vertebral y el plexo braquial y, frecuentemente, corresponden una compresión combinada de ellos 6,[11][12][13][14] . Las compresiones son casi siempre anatómicamente bilaterales [14][15][16] , aunque a menudo son sintomáticas en un solo lado.…”