Written by Nedal Katib, Prince of Wales, Sydney Australia
Thoracic Outlet Syndrome = A constellation of signs and symptoms relating to the compression of the neurovascular structures that occurs as these structures travel between the thoracic aperture and the upper limb.
Types: Neurogenic, Venous and Arterial
Understanding the anatomy of what is collectively referred to as the thoracic outlet is the best way to thoroughly appreciate this topic.
Three spaces where the neurovascular structures are at risk of compression:
Appreciating the attachments of the Anterior and Middle Scalene Muscles on the first rib becomes important in the diagnosis of the various types and also the ultimate surgical management of the compression.
The First Rib:
The Coracoid Process:
Pectoralis Minor Muscle:
Phrenic Nerve Anomaly:
Anomalous anatomy can also cause TOS especially when patients have a Cervical Rib and anomalous first ribs or a congenital band attaching to the first rib.
Provocative manoeuvres are largely used for nTOS. While these are described and mentioned in most texts their utility largely is beyond the scope of a vascular surgeon’s assessment and diagnosis of nTOS.
Roos Test / EAST test
Paget Schroetter Syndrome
Rib Resection approaches
Cosmetically more appealing as it has a limited hidden scar
-Good for scalene triangle access and debulking and cervical rib resection
-Required for aTOS if arterial reconstruction necessary
-Good access for venous decompression
-Allows for excision of subclavius muscle and costoclavicular ligament
-Difficult to visualise the anatomy, dependent on good assistance
-Risk of T1 nerve root injury, subclavian vein injury and arterial injury with limited
exposure to repair
-Not able to approach cervical ribs, scalene triangle or patch vein.
-Unable to decompress venous compression or visualise vein adequately
-cosmetically less appealing
-Unable to expose subclavian artery
-Difficult to access most posterior aspect of rib
- Cosmetically less appealing
History in vTOS
Goals of therapy for vTOS - Limited evidence due to lack of RCT’s. Majority of evidence based on retrospective studies.
Initial management strategy for vTOS
Controversy around vTOS
Landmark papers regarding vTOS and what are the take home messages
Presentation of aTOS
Important differentials for aTOS
Most common causes of aTOS - The different Anatomical Abnormalities causing aTOS (incidence %)
Scher Staging of aTOS
Management considerations with aTOS
Demographics of nTOS
Neurogenic TOS is largely a clinical diagnosis with symptoms and signs pertaining to nerve compression most commonly the lower trunk of the brachial plexus.
Presentation of nTOS
The role of the Vascular Surgeon with nTOS - Often these patients have already seen multiple specialists and physiotherapists.
Surgery with Rib resection often is accomplished with transaxillary or supraclavicular approach, particularly if scalenectomy or cervical rib resection is necessary.
 Rutherford Eight Edition – Chapter 125 Wei Lum/Freischlag
 Valentine and Wind – Anatomic Exposures in Vascular Surgery second edition
 LASTS anatomy Ninth Edition RMH McMinn
 Rutherford Eighth Edition – Chapter 128 Louis M. Messina
 Rajput et al – Yearbook of Vascular and Endovascular Surgery 2018
 Illig KA et al A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010
 ACCP guidelines 2016
 Urschel HC Jr et al - Ann Thorac Surg. 2008
 Grunwald et al – J Vasc Interv Radiol 2004
Wilson JJ et al – Am J Surg 1990
 Rutherford Eighth Edition – Chapter 127 Melissa L. Kirkwood and R.James Valentine