Thoracic Outlet Obstruction Treatment & Management
- Author: Mark K Eskandari, MD; Chief Editor: Vincent Lopez Rowe, MD more...
Neurogenic thoracic outlet syndrome
Physical therapy has an important role in the initial treatment of neurogenic thoracic outlet syndrome (TOS). Postural exercises, stretching, abdominal breathing, and medications used to relieve muscular tension and pain are beneficial. Abdominal breathing and postural exercises relax the neck musculature, which helps to relieve symptoms.
Approximately 60% of patients improve significantly with conservative treatment alone. The indication for surgical treatment of neurogenic TOS is the failure of conservative treatment in a patient with disability so severe that the patient is unable to work or live comfortably. Most physicians prescribe 3-12 months of physical therapy prior to considering surgical decompression of the thoracic outlet.
Arterial thoracic outlet syndrome
No satisfactory medical treatment for arterial TOS exists. These patients usually present with a history of thromboembolic complications and require surgical repair. Arterial TOS requires prompt surgical intervention to treat or prevent acute thromboembolic events.
Confusion may occur when a patient presents with an upper-extremity thromboembolic event and no identifiable source. If a cervical rib or an aberrant first rib is identified under these circumstances, opening the artery and examining for intimal lesions has been proposed. If an intimal lesion is found, then the patient should undergo thoracic outlet decompression and repair of the artery.
Endovascular repair of subclavian arterial aneurysms has been described, but this treatment modality does not abolish the need for surgical decompression. Aneurysm resection and arterial replacement remains the preferred treatment. Endovascular treatment of large arterial aneurysms may be useful when a difficult exposure is anticipated.
Venous thoracic outlet syndrome
Treatment for venous TOS–related effort thrombosis that relies on anticoagulation and arm elevation leaves 74% of patients with residual disability and 12% with significant complication. Thrombolytic therapy generally is preferred to venous thrombectomy; however, thrombectomy still may play a role in some cases with low surgical risk and contraindication to thrombolytic therapy.
Although thrombolytic therapy alone is superior to simple anticoagulation in patients who present with venous TOS, the patients who achieve the best results are those who are treated with thrombolytics and surgical decompression. Unfortunately, most primary care and emergency department (ED) physicians do not appreciate or share this view, and as a result, most patients with venous TOS are not treated aggressively.
Venous thoracic outlet obstruction
Surgical treatment of venous TOS consists of releasing the extrinsic compression and restoring luminal patency. The traditional view was that a staged approach would be more beneficial, with surgical decompression deferred until several weeks after thrombolytic intervention. The presumed advantage allowed for resolution of the inflammatory response before embarking on the surgical procedure. Subsequent data suggested that a more uniform approach, with treatment completed during a single hospitalization, may be a better option.[7, 8]
If a residual lesion is less than 2 cm long, perform a thrombectomy with vein patch angioplasty and venolysis during decompression surgery. An alternative option is to perform vein angioplasty in a staggered fashion after decompressive surgery or, as Schneider et al have suggested, at the same time as open decompressive surgery. Other authors have cautioned against vein angioplasty at the time of decompressive surgery out of concern that a bleeding complication is more likely.
A lesion longer than 2 cm may require venous bypass or a jugular vein turndown procedure. A consensus statement favored conservative treatment with anticoagulation under these circumstances and concluded that venous bypass should be reserved for only those patients with disabling symptoms and serious complications.
Neurogenic/arterial thoracic outlet obstruction
Thoracic outlet decompression can be performed through an axillary, supraclavicular, or posterior approach, and the choice usually is based on surgeon preference. In neurogenic TOS, results are equal, and the approach or operation performed for TOS may be selected irrespective of the presenting neurologic symptoms.
For arterial TOS, the operation can be performed using the axillary, supraclavicular, or combined supraclavicular-infraclavicular approach. If the supraclavicular approach is utilized, an infraclavicular counterincision always can be performed for added exposure. The supraclavicular approach is becoming more popular and may be superior for total surgical decompression of the thoracic outlet.
Thoracic outlet decompression may entail anterior and middle scalenectomy, first-rib resection, or scalenectomy plus first-rib resection. Reports of scalenectomy versus first-rib resection have noted similar results for the two procedures, irrespective of the procedure performed. Sanders et al noted no difference in results when the procedure was rib resection only, anterior and middle scalenectomy, or combined first-rib resection plus scalenectomy.
A transclavicular approach via resection of the midclavicle or the medial two thirds of the clavicle also has been reported for repair of arterial pathology. An alternative approach utilizes both supraclavicular and infraclavicular incisions to achieve the necessary exposure.
Plan arterial reconstruction when an arterial aneurysm or mural thrombus is identified; either autogenous or prosthetic repair can be performed, though autogenous repair with the saphenous vein usually is preferred. Vein graft aneurysms in the subclavian position may occur over time and with greater frequency than in other positions.
Treat embolic events causing ischemia with embolectomy and reconstruction as necessary. Clinical results are good if initial surgical management has been appropriate.
Nerve injuries, lymph leak, and bleeding are the most common postoperative complications. Phrenic, long thoracic, and sympathetic nerves are at risk of injury during this procedure. Injury to the sympathetic nerves results in Horner syndrome. Persistent lymph leak may follow injury to the thoracic duct and is more common following operations on the left side. Fewer than 1% of lymph leaks require reoperation for treatment. Postoperative hemorrhage may be difficult to control, especially after transaxillary decompression, because of poor exposure of vascular structures.
Outcome and Prognosis
Most patients do not experience full relief of symptoms after surgery for neurogenic TOS. A good result occurs when partial relief is achieved and symptoms do not progress. Approximately 40-80% of patients who undergo surgical treatment have some relief of symptoms. Approximately 10-15% of patients who initially experience symptomatic relief have recurrence of symptoms.
If only first-rib resection was performed, these patients may benefit from anterior and middle scalenectomy along with neurolysis. If only scalenectomy was performed, a second operation with first-rib resection and neurolysis may be considered. Only 40% of patients experience long-term symptomatic relief after reoperation for TOS.
Patients with arterial and venous TOS usually do well if workup and treatment have been appropriate.
Future and Controversies
Continued clinical investigation may help better define the timing of thoracic outlet decompression after thrombolytic therapy for Paget-Schroetter syndrome. In addition, better patient selection may improve the results for neurogenic TOS. A randomized prospective study would be helpful in determining optimal treatment for patients with neurogenic TOS; however, because of the relative rarity of this condition, multi-institutional participation would be required.
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