eMedicine Specialties > Vascular Surgery > Medical Topics

Thoracic Outlet Obstruction: Treatment

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

Treatment

Medical Therapy

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.

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.

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 over venous thrombectomy; however, thrombectomy still may have 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 or emergency department (ED) physicians do not appreciate or share this view, so most patients with venous TOS are not treated aggressively.

Surgical Therapy

Venous thoracic outlet obstruction

Surgical treatment of venous TOS consists of releasing the extrinsic compression and restoring luminal patency.  Traditional therapy suggested 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.  More recent data suggest that a more uniform approach with treatment completed during a single hospitalization may be a better option.

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 following decompressive surgery or, as Schneider et al have recently 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 venous TOS, the operation can be performed using the axillary, supraclavicular, or combined supraclavicular/infraclavicular approach. If the supraclavicular approach is utilized, an infraclavicular counter-incision 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 both 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 mid clavicle or 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, although 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.

Complications

Nerve injuries, lymph leak, and bleeding are the most common complications following surgery. 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. Less than 1% of lymph leaks require reoperation for treatment. Of note, postoperative hemorrhage may be difficult to control, especially following transaxillary decompression because of poor exposure of vascular structures.

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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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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