October 27, 2005

Therapeutic Planning in the Treatment of Arterial Thoracic Outlet Syndrome.

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David Cassada, MD, Brian K. Reed, MD, Scott Stevens, MD, Michael Freeman, MD, Mitchell Goldman, MD.
University of Tennessee Medical Center, Knoxville, TN, USA.

BACKGROUND:
Upper extremity arterial compromise secondary to thoracic outlet syndrome (TOS) is a rare cause for limb loss. It is becoming increasingly understood that there are multiple potential sites for arterial compression within the neck and shoulder girdle. The anatomy of arterial compression and vessel damage requires a tailored surgical approach to provide both relief of structural constraints and to reconstruct diseased arterial segments. This study serves to review a recent clinical experience in the treatment of arterial TOS, and to suggest an algorithm for treatment.
METHODS:
Between July 2002 and July 2005, 16 patients underwent evaluation for arterial TOS, with one bilateral. Presenting symptoms included critical arm ischemia (4), digital arterial emboli (5), and positional arm claudication. Management included physical therapy with anti-platelet medication (3), anterior scalenectomy (1), rib resection and anterior scalenectomy (5), rib resection with anterior scalenectomy and pectorial tenotomy (2), rib resection with anterior scalenectomy and revascularization (4), pectoralis tenotomy alone (1), and pectoralis tenotomy with revascularization (1). Therapeutic decision-making was directed by physical examination, severity/duration of symptoms, upper extremity plethysmography or angiography with arm abduction maneuvers.

RESULTS:
Resolution of critical ischemia was achieved in 75% of patients, and digital arterial embolic disease ceased after decompression in 100% of patients. Positional claudication was improved in 6 of 7 patients, and one patient had persistently abnormal waveforms with TOS maneuvers after decompression.

Symptoms	Nonoperative	Decompression	Decompression with Revascularization	Persistent Symptoms
Positional Claudication	3	3	1	1
Thromboembolism	0	5	0	0
Critical Ischemia	0	0	4	2 (1 limb loss)

There was no correlation between the presence of a cervical rib and severity of disease or success of therapy. Time (days) to intervention was a clinical predictor of surgical failure in patients with arterial embolism and acute critical ischemia (ANOVA p<0.05).

CONCLUSIONS:
TOS can result in arm arterial compression with consequences ranging from nuisance pain to limb loss. Understanding the variability in the anatomy of vascular compression directs surgical decision-making. The timeline of transition from pain to arterial embolism and tissue loss sets a cadence for the degree of surgical intervention and may inversely relate to outcome.

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