eMedicine Specialties > Vascular Surgery > Medical Topics

Thoracic Outlet Obstruction: Workup

Author: Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Coauthor(s): Nicholas D Garcia, MD, Chief of Surgery, Exeter Health Resources; Director, Board of Directors, Core Physician Services; Medical Director, Vascular Lab, Exeter Hospital; Mark D Morasch, MD, Associate Professor of Surgery, Division of Vascular Surgery, Northwestern University, The Feinberg School of Medicine
Contributor Information and Disclosures

Updated: Nov 2, 2009

Workup

Laboratory Studies

  • No laboratory studies are required for the workup of thoracic outlet syndrome (TOS) because no laboratory study aids in the diagnosis of this condition.
  • Laboratory studies are useful to rule out other diseases, such as a hypercoagulable state in venous thrombosis, and they also may be useful to prepare a patient for general anesthesia.

Imaging Studies

  • Chest radiography may be helpful when evaluating patients with neurogenic or arterial TOS. Cervical ribs or rudimentary first ribs often can be identified on chest radiography.
  • Standard CT scanning may help to rule out other pathologies that might cause symptoms mimicking TOS. For example, a herniated cervical disc or spinal stenosis is diagnosed by CT scanning.
    • CT scanning with 3-dimensional reconstruction have become popular for evaluating the thoracic outlet. With the use of 3-dimensional CT scanning, compression of the structures at the thoracic outlet can be demonstrated clearly using dynamic positioning (see Images 3-4).

    • Thoracic outlet obstruction. Three-dimensional CT...

      Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery at the thoracic outlet.

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      Thoracic outlet obstruction. Three-dimensional CT...

      Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery at the thoracic outlet.


    • Thoracic outlet obstruction. Three-dimensional CT...

      Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery with the arm abducted.

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      Thoracic outlet obstruction. Three-dimensional CT...

      Thoracic outlet obstruction. Three-dimensional CT scan showing subclavian artery with the arm abducted.

    • CT scan angiography (see Images 5-6) and venography (see Images 7-8) can produce excellent images using maximal intensity projection (MIP).

    • Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery in the neutral position.

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      Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery in the neutral position.


    • Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery when arm is abducted.

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      Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian artery when arm is abducted.


    • Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in neutral position.

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      Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in neutral position.


    • Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in abducted position.

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      Thoracic outlet obstruction. CT scan, maximal int...

      Thoracic outlet obstruction. CT scan, maximal intensity projection (MIP), showing subclavian vein in abducted position.

  • Standard MRI also can be used to rule out alternative diagnoses. Dynamic MRI with gadolinium infusion provides detail of the thoracic outlet and may be helpful when evaluating for compression. Gadolinium-enhanced magnetic resonance angiography is thought to hold significant potential for imaging the thoracic outlet.
  • Angiography with dynamic positioning is used to demonstrate compression of the subclavian artery. Angiography may identify axillary-subclavian aneurysm (see Image 9), and if an aneurysm is present, it is useful in planning surgery. Arterial stenosis with poststenotic dilatation also may be identified angiographically.

  • Thoracic outlet obstruction. Angiogram showing su...

    Thoracic outlet obstruction. Angiogram showing subclavian artery aneurysm in abduction/external rotation (AER).

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    Thoracic outlet obstruction. Angiogram showing su...

    Thoracic outlet obstruction. Angiogram showing subclavian artery aneurysm in abduction/external rotation (AER).

  • Venography with dynamic positioning demonstrates abnormalities of the subclavian vein in patients with Paget-Schroetter syndrome (see Image 10). Interestingly, venography of the contralateral arm of patients with venous TOS identifies compression with dynamic positioning in as many as 80% of patients. Despite the compression that occurs in the contralateral extremity, the incidence of contralateral DVT is only 15%. During venography, abduct patients' arms to only 30° to avoid an erroneous diagnosis of complete vein occlusion. Always perform provocative maneuvers under fluoroscopy to document venous compression in patients with presumed Paget-Schroetter syndrome. If compression of the vein is not identified at 30 degrees of abduction, then rotation of the neck, flexion or extension of the neck, or further abduction may be useful.

  • Thoracic outlet obstruction. Venogram showing ven...

    Thoracic outlet obstruction. Venogram showing venous stenosis.

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    Thoracic outlet obstruction. Venogram showing ven...

    Thoracic outlet obstruction. Venogram showing venous stenosis.

  • In venous TOS, ultrasonography is useful as a noninvasive test to search for collateral circulation and evaluate the extent of thrombosis. Identification of significant collaterals may help with operative planning, and may determine the type of exposure used in order to limit damage to these collaterals. In arterial TOS, ultrasonography can document stenosis, poststenotic dilatation or aneurysm of the subclavian artery, and mural thrombus.

Other Tests

  • Electromyography (EMG) and nerve conduction studies are useful in the workup of patients suspected of having neurogenic TOS. Findings on EMG usually are normal in patients with TOS, but it is helpful in ruling out other neuromuscular problems. Nerve conduction velocity studies usually are more helpful than EMG studies. A reduction in nerve conduction velocity of less than 85 m/s of either ulnar or median nerves across the thoracic outlet corroborates the diagnosis of neurogenic TOS. These studies also can be used as baseline values prior to treatment.
  • Carefully examine the scalene muscles and supraclavicular fossa when evaluating a patient with neurogenic TOS. Scalene muscle block with local anesthetic has a 94% correlation with good early results of surgery.
  • The Adson sign is the loss of the radial pulse by rotating the head to the ipsilateral side and inspiring. A positive test result was considered pathonomic for TOS, but the Adson test no longer is considered reliable because these findings occur in as many as 53% of subjects without TOS.

Histologic Findings

Muscle biopsy specimens show that type I fibers predominate and type II fibers atrophy in patients with neurogenic thoracic outlet syndrome (TOS). Increased fibrosis also has been noted in the scalene muscles of these patients. These findings suggest that repetitive trauma may have a role in the development of neurogenic symptoms.

More on Thoracic Outlet Obstruction

Overview: Thoracic Outlet Obstruction
Workup: Thoracic Outlet Obstruction
Treatment: Thoracic Outlet Obstruction
Follow-up: Thoracic Outlet Obstruction
Multimedia: Thoracic Outlet Obstruction
References
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References

  1. Machleder HI, Moll F, Verity MA. The anterior scalene muscle in thoracic outlet compression syndrome. Histochemical and morphometric studies. Arch Surg. Oct 1986;121(10):1141-4. [Medline].

  2. Davidovic LB, Koncar IB, Pejkic SD, Kuzmanovic IB. Arterial complications of thoracic outlet syndrome. Am Surg. Mar 2009;75(3):235-9. [Medline].

  3. AbuRahma AF, Sadler D, Stuart P, Khan MZ, Boland JP. Conventional versus thrombolytic therapy in spontaneous (effort) axillary-subclavian vein thrombosis. Am J Surg. Apr 1991;161(4):459-65. [Medline].

  4. Adams JT, DeWeese JA. "Effort" thrombosis of the axillary and subclavian veins. J Trauma. Nov 1971;11(11):923-30. [Medline].

  5. Adelman MA, Stone DH, Riles TS, Lamparello PJ, Giangola G, Rosen RJ. A multidisciplinary approach to the treatment of Paget-Schroetter syndrome. Ann Vasc Surg. Mar 1997;11(2):149-54. [Medline].

  6. Arko FR, Harris EJ, Zarins CK, Olcott C 4th. Vascular complications in high-performance athletes. J Vasc Surg. May 2001;33(5):935-42. [Medline].

  7. Axelrod DA, Proctor MC, Geisser ME, Roth RS, Greenfield LJ. Outcomes after surgery for thoracic outlet syndrome. J Vasc Surg. Jun 2001;33(6):1220-5. [Medline].

  8. Caparrelli DJ, Freischlag J. A unified approach to axillosubclavian venous thrombosis in a single hospital admission. Semin Vasc Surg. Sep 2005;18(3):153-7. [Medline].

  9. Cheng SW, Stoney RJ. Supraclavicular reoperation for neurogenic thoracic outlet syndrome. J Vasc Surg. Apr 1994;19(4):565-72. [Medline].

  10. Cormier JM, Amrane M, Ward A, Laurian C, Gigou F. Arterial complications of the thoracic outlet syndrome: fifty-five operative cases. J Vasc Surg. Jun 1989;9(6):778-87. [Medline].

  11. Gelabert HA, Machleder HI. Diagnosis and management of arterial compression at the thoracic outlet. Ann Vasc Surg. Jul 1997;11(4):359-66. [Medline].

  12. Gergoudis R, Barnes RW. Thoracic outlet arterial compression: prevalence in normal persons. Angiology. Aug 1980;31(8):538-41. [Medline].

  13. Green RM, McNamara J, Ouriel K. Long-term follow-up after thoracic outlet decompression: an analysis of factors determining outcome. J Vasc Surg. Dec 1991;14(6):739-45; discussion 745-6. [Medline].

  14. Hagspiel KD, Spinosa DJ, Angle JF, Matsumoto AH. Diagnosis of vascular compression at the thoracic outlet using gadolinium-enhanced high-resolution ultrafast MR angiography in abduction and adduction. Cardiovasc Intervent Radiol. Mar-Apr 2000;23(2):152-4. [Medline].

  15. Hill SL, Berry RE. Subclavian vein thrombosis: a continuing challenge. Surgery. Jul 1990;108(1):1-9. [Medline].

  16. Juvonen T, Satta J, Laitala P, Luukkonen K, Nissinen J. Anomalies at the thoracic outlet are frequent in the general population. Am J Surg. Jul 1995;170(1):33-7. [Medline].

  17. Landry GJ, Moneta GL, Taylor LM Jr, Edwards JM, Porter JM. Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. J Vasc Surg. Feb 2001;33(2):312-7; discussion 317-9. [Medline].

  18. Lang EK. Scalenus anticus and pectoralis minor syndrome. J Indiana State Med Assoc. Apr 1967;60(4):440. [Medline].

  19. Lee WA, Hill BB, Harris EJ Jr, Semba CP, Olcott C IV. Surgical intervention is not required for all patients with subclavian vein thrombosis. J Vasc Surg. Jul 2000;32(1):57-67. [Medline].

  20. Lindgren KA, Oksala I. Long-term outcome of surgery for thoracic outlet syndrome. Am J Surg. Mar 1995;169(3):358-60. [Medline].

  21. Lokanathan R, Salvian AJ, Chen JC, Morris C, Taylor DC, Hsiang YN. Outcome after thrombolysis and selective thoracic outlet decompression for primary axillary vein thrombosis. J Vasc Surg. Apr 2001;33(4):783-8. [Medline].

  22. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg. Feb 1993;17(2):305-15; discussion 316-7. [Medline].

  23. Molina JE, Hunter DW, Dietz CA. Paget-Schroetter syndrome treated with thrombolytics and immediate surgery. J Vasc Surg. Feb 2007;45(2):328-34. [Medline].

  24. Monreal M, Lafoz E, Ruiz J, Valls R, Alastrue A. Upper-extremity deep venous thrombosis and pulmonary embolism. A prospective study. Chest. Feb 1991;99(2):280-3. [Medline].

  25. Monreal M, Raventos A, Lerma R. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines--a prospective study. Thromb Haemost. Oct 1994;72(4):548-50. [Medline].

  26. Nakada T, Knight RT, Mani RL. Intermittent venous claudication of the upper extremity: the pectoralis minor syndrome. Ann Neurol. Apr 1982;11(4):433-4. [Medline].

  27. Nehler MR, Taylor LM Jr, Moneta GL, Porter JM. Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg. May 1997;132(5):527-32. [Medline].

  28. Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg [Am]. Jul 1995;20(4):542-8. [Medline].

  29. Parziale JR, Akelman E, Weiss AP. Thoracic outlet syndrome. Am J Orthop. May 2000;29(5):353-60. [Medline].

  30. Rutherford RB, Hurlbert SN. Primary subclavian-axillary vein thrombosis: consensus and commentary. Cardiovasc Surg. Aug 1996;4(4):420-3. [Medline].

  31. Sanders RJ, Cooper MA, Hammond SL, et al. Neurogenic thoracic outlet syndrome. In: Gloviczki P, et al, eds. Rutherford Vascular Surgery. 5th ed. Philadelphia, Pa:. W.B. Saunders Company;2000:1184-1201.

  32. Sanders RJ, Hammond SL. Subclavian vein obstruction without thrombosis. J Vasc Surg. Feb 2005;41(2):285-90. [Medline].

  33. Sanders RJ, Haug CE, Pearce WH. Recurrent thoracic outlet syndrome. J Vasc Surg. Oct 1990;12(4):390-8; discussion 398-400. [Medline].

  34. Sanders RJ, Huag CE. Thoracic Outlet Syndrome: A Common Sequela of Neck Injuries. Philadelphia, Pa:. JB Lippincott;1991.

  35. Sanders RJ, Pearce WH. The treatment of thoracic outlet syndrome: a comparison of different operations. J Vasc Surg. Dec 1989;10(6):626-34. [Medline].

  36. Schneider DB, Dimuzio PJ, Martin ND. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty. J Vasc Surg. Oct 2004;40(4):599-603. [Medline].

  37. Sheeran SR, Hallisey MJ, Murphy TP, Faberman RS, Sherman S. Local thrombolytic therapy as part of a multidisciplinary approach to acute axillosubclavian vein thrombosis (Paget-Schroetter syndrome). J Vasc Interv Radiol. Mar-Apr 1997;8(2):253-60. [Medline].

  38. Southam AH, Bythell WJ. Cervical ribs in children. Br Med J. 1924;2:844-55.

  39. Szeimies U, Kueffer G, Stoeckelhuber B. Successful exclusion of subclavian aneurysms with covered nitinol stents. Cardiovasc Intervent Radiol. May-Jun 1998;21(3):246-9. [Medline].

  40. Thompson RW, Schneider PA, Nelken NA, Skioldebrand CG, Stoney RJ. Circumferential venolysis and paraclavicular thoracic outlet decompression for "effort thrombosis" of the subclavian vein. J Vasc Surg. Nov 1992;16(5):723-32. [Medline].

  41. Urschel HC Jr, Razzuk MA. Improved management of the Paget-Schroetter syndrome secondary to thoracic outlet compression. Ann Thorac Surg. Dec 1991;52(6):1217-21. [Medline].

  42. Wilson JJ, Zahn CA, Newman H. Fibrinolytic therapy for idiopathic subclavian-axillary vein thrombosis. Am J Surg. Feb 1990;159(2):208-10; discussion 210-1. [Medline].

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Further Reading

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Keywords

thoracic outlet obstruction, thoracic outlet syndrome, TOS, venous thoracic outlet syndrome, venous TOS, arterial thoracic outlet syndrome, neurogenic thoracic outlet syndrome, Paget-Schroetter syndrome

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Contributor Information and Disclosures

Author

Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Mark K Eskandari, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, International Society of Endovascular Specialists, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Interventional Radiology, Society of University Surgeons, and Western Surgical Association
Disclosure: Terumo Consulting fee Consulting; W. L. Gore & Associates Consulting fee Consulting; Abbott Vascular Consulting fee Consulting; Cordis Consulting fee Consulting; Boston Scientific Consulting fee Consulting

Coauthor(s)

Nicholas D Garcia, MD, Chief of Surgery, Exeter Health Resources; Director, Board of Directors, Core Physician Services; Medical Director, Vascular Lab, Exeter Hospital
Nicholas D Garcia, MD is a member of the following medical societies: American College of Surgeons, New Hampshire Medical Society, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Mark D Morasch, MD, Associate Professor of Surgery, Division of Vascular Surgery, Northwestern University, The Feinberg School of Medicine
Mark D Morasch, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, and Central Surgical Association
Disclosure: W.L. Gore & Associates Honoraria Speaking and teaching; W.L. Gore & Associates Grant/research funds None; Cryolife Honoraria Consulting; King Pharmaceuticals  Honoraria Consulting

Medical Editor

Jeffrey Lawrence Kaufman, MD, Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine
Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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