Hyperabduction During Balloon Inflation in the Subclavian Vein as a Test for Thoracic Outlet Syndrome.

We present a case of venous thoracic outlet syndrome involving upper extremity venous thrombosis confirmed by hyperabduction during balloon inflation in the subclavian vein. This provocative test provides clear evidence of extrinsic venous compression, confirming venous thoracic outlet syndrome.

Predisposing Anatomy for Thoracic Outlet Syndrome and Functional Outcomes after Supraclavicular Thoracic Outlet Decompression in Athletes.

Purpose: This study aims to examine predisposing anatomic factors and subsequent post-decompression functional outcomes among high-intensity athletes with thoracic outlet syndrome (TOS). Materials and Methods: A single-institution retrospective review was performed on a prospective database of patients with TOS from 2018 to 2023 who had undergone operative decompression for TOS. Demographics, TOS characteristics, predisposing anatomy, operative details, and postoperative outcomes were examined. The primary outcome was postoperative return to sport. Secondary outcomes included vascular patency. Results: A total of 13 patients who were engaged in high-demand athletic activity at the time of their diagnosis were included. Diagnoses included 8 (62%) patients with venous TOS, 4 (31%) patients with neurogenic TOS, and 1 (8%) patient with arterial TOS. Mixed vascular and neurogenic TOS was observed in 3 (23%) patients. The mean age of the cohort was 30 years. Abnormal scalene structure was observed in 12 (92%) patients, and abnormal bone structures were noted in 4 (27%) patients; 2 (15%) with cervical ribs and 3 (23%) patients with clavicular abnormalities. Prior ipsilateral upper extremity trauma was reported in 4 (27%) patients. Significant joint hypermobility was observed in 8 (62%) patients with a median Beighton score of 6. Supraclavicular cervical and/or first rib resection with scalenectomy was performed in all patients. One case of postoperative pneumothorax was treated non-operatively. Ten (77%) patients returned to sport. Duplex ultrasonography showed subclavian vein patency in all 8 patients with venous TOS and wide patency with no drop in perfusion indices in the patient with arterial TOS. Conclusion: Athletes with TOS who required operative intervention had a high incidence of musculoskeletal aberrations and joint hypermobility. Supraclavicular decompression was associated with a high success rate, with overall good functional outcomes and good likelihood of patients returning to preoperative high-intensity athletics.

Surgical outcomes for occluded venous thoracic outlet syndrome following transaxillary first rib resection.

OBJECTIVE: Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS. METHODS: We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ2 test to compare baseline characteristics and postoperative outcomes. RESULTS: Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84). CONCLUSIONS: TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency.

Analysis of Completion Intraoperative Venography During First Rib Resection for Venous Thoracic Outlet Syndrome.

INTRODUCTION: We evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (vTOS). METHODS: We performed a retrospective, single-center review of all patients with vTOS treated with First Rib Resection and intraoperative venography from 2011 - 2023. We reviewed intraoperative venographic films to classify findings, collected demographics, clinical and perioperative variables, and clinical outcomes. Primary endpoints were symptomatic relief and primary patency at 3 months and 1 year. Secondary endpoints were time free from symptoms, reintervention rate, perioperative complications, and mortality. RESULTS: Fifty-one AxSCVs (49 patients, mean age of 31.3 ± 12.6, 52.9% female) were treated for vTOS with first rib resection and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Prior to FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with No Stenosis (Group 1, 31.3%), 17 with No Stenosis after Angioplasty (Group 2, 33.3%), 10 with Residual Stenosis after Angioplasty (Group 3, 19.7%), and 8 with Complete Occlusion (Group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (Group 1: 14 of 16, Group 2: 13 of 17, Group 3: 10 of 10, and Group 4: 7 of 8; Log-Rank Test, p = 0.5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (Group 1: 16 of 16 and 9 of 9; Group 2: 16 of 17 and 12 of 13; Group 3: 10 of 10, 5 of 5; Group 4: primary patency not obtained). There was one asymptomatic re-thrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. CONCLUSION: Our single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief, short- and mid-term patency despite residual venous stenosis and complete occlusion. While completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.

Upper-limb neurovascular compression, pectoralis minor and quadrilateral space syndromes: A narrative review of current literature.

Pectoralis minor syndrome (PMS) and quadrilateral space syndrome (QSS) are uncommon neurovascular compression disorders affecting the upper extremity. PMS involves compression under the pectoralis minor muscle, and QSS results from compression in the quadrilateral space-both are classically observed in overhead-motion athletes. Diagnosing PMS and QSS may be challenging due to variable presentations and similarities with other, more common, upper-limb pathologies. Although there is no gold standard diagnostic, local analgesic muscle-block response in a patient with the appropriate clinical context is often all that is required for an accurate diagnosis after excluding more common etiologies. Treatment ranges from conservative physical therapy to decompressive surgery, which is reserved for refractory cases or severe, acute vascular presentations. Decompression generally yields favorable outcomes, with most patients experiencing significant relief and restored baseline function. In conclusion, PMS and QSS, although rare, can cause debilitating upper-extremity symptoms; accurate diagnosis and appropriate treatment offer excellent outcomes, alleviating pain and disability.

The supraclavicular approach to decompression of the thoracic outlet.

Surgical decompression of the thoracic outlet, along with treatment of the involved nerve or vessel, is the accepted treatment modality when indicated. Although neurogenic thoracic outlet syndrome (TOS) is often operated via the axillary approach and venous TOS via the paraclavicular approach, arterial TOS is almost always operated via the supraclavicular approach. The supraclavicular approach provides excellent access to the artery, brachial plexus, phrenic nerve, and the cervical and/or first ribs, along with any bony or fibrous or muscular abnormality that may be causing compression of the neurovascular structures. Even for neurogenic TOS, for which the axillary approach offers good cosmesis, the supraclavicular approach helps with adequate decompression while preserving the first rib. This approach may also be sufficient for thin patients with venous TOS. For arterial TOS, a supraclavicular incision usually suffices for excision of bony abnormality and repair of the subclavian artery.

Thoracic outlet syndrome in women.

Thoracic outlet syndrome (TOS) is observed more frequently in women, although the exact causes of this sex disparity remain unclear. By investigating the three types of TOS-arterial, neurogenic, and venous-regarding symptoms, diagnosis, and treatment, this article aims to shed light on the current understanding of TOS, focusing on its variations in women.

Trans-axillary thoracic outlet decompression.

Thoracic outlet syndrome (TOS) is a group of conditions thought to be caused by the compression of neurovascular structures going to the upper extremity. TOS is a difficult disease to diagnose, and surgical treatment remains challenging. Many different surgical techniques for the treatment of TOS have been described in the literature and many reasonable to good outcomes have been reported, which makes it hard for surgeons to determine which techniques should be used. Our aim was to describe the rationale, techniques, and outcomes associated with the surgical treatment of TOS. Most patients in our center are treated primarily through a trans-axillary approach. We will elaborate on the technical details of performing trans-axillary thoracic outlet decompression. The essential steps during surgery are illustrated with videos. We focused on the idea behind performing a trans-axillary thoracic outlet decompression in primary cases. Institutional data on the outcomes of this surgical approach are described briefly.

Video-assisted thoracic surgery and robotic-assisted first-rib excision and thoracic outlet syndrome decompression.

Multiple surgical approaches have been used in the management of thoracic outlet syndrome. These approaches have traditionally been "open" approaches and have been associated with the inherent morbidities of an open approach, including a risk of injury to the neurovascular structures due to traction and trauma while resecting the first rib. In addition, there has been concern that recurrence of symptoms may be related to incomplete resection of the rib with conventional open techniques. With the advent of minimally invasive thoracic surgery, surgeons began to explore first-rib resection via a thoracoscopic approach. Unfortunately, the existing video-assisted thoracic surgery technology and equipment was not well suited to working in the apex of the chest. With the introduction and subsequent progress in robotic surgery and instrumentation, this dissection can be performed with all the advantages of robotics, but also with minimal traction and trauma to the neurovascular structures, and incorporates almost complete resection of the rib with minimal residual stump. Robotics has developed as a reliable, safe, and less invasive approach to first-rib resection, yielding excellent results while limiting the morbidity of the procedure.

The infraclavicular approach for venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (vTOS) is an esoteric condition that presents in young, healthy adults. Treatment includes catheter-directed thrombolysis, followed by first-rib resection for decompression of the thoracic outlet. Various techniques for first-rib resection have been described with successful outcomes. The infraclavicular approach is well-suited to treat the most medial structures that are anatomically relevant for vTOS. A narrative review was conducted to specifically examine the literature on infraclavicular exposure for vTOS. The technique for this operation is described, as well as the advantages and disadvantages of this approach. The infraclavicular approach is a reasonable choice for definitive treatment of uncomplicated vTOS.

Systematic review of intermediate and long-term results of thoracic outlet decompression.

Thoracic outlet syndrome (TOS) consists of a group of disorders resulting from compression of the neurovascular bundle exiting through the thoracic outlet. TOS can be classified as follows based on the etiology of the pathophysiology: neurogenic TOS, venous TOS, arterial TOS, and mixed TOS. The constellation of symptoms a patient may experience varies, depending on the structures involved. Due to the wide range of etiologies and presenting symptoms, treatments for TOS also differ. Furthermore, most studies focus on the perioperative and short-term outcomes after surgical decompression for TOS. This systematic review aimed to provide a pooled analysis of studies to better understand the intermediate and long-term outcomes of surgical decompression for TOS. We conducted a systematic literature search in the Ovid MEDLINE, Embase, and Google Scholar databases for studies that analyzed long-term outcomes after surgical decompression for TOS. The inclusion period was from January 2015 to May 2023. The primary outcome was postoperative QuickDASH Outcome Measure scores. A total of 16 studies were included in the final analysis. The differences between postoperative and preoperative QuickDASH Outcome Measure scores were calculated, when possible, and there was a mean overall difference of 33.5 points (95% CI, 25.2-41.8; P = .001) after surgical decompression. There was a higher proportion of excellent outcomes reported for patients undergoing intervention for arterial and mixed TOS etiologies, whereas those with venous and neurogenic etiologies had the lowest proportion of excellent outcomes reported. Patients with neurogenic TOS had the highest proportion of poor outcomes reported. In conclusion, surgical decompression for TOS has favorable long-term outcomes, especially in patients with arterial and mixed etiologies.

McCleery Syndrome Caused by Pectoralis Minor Hypertrophy Treated with Multimodal Physical Therapy-A Case Report.

We present a case of a healthy young male professional water polo player who presented with swelling and pain in the upper arm and elbow after vigorous exercise. Diagnostic workup included an MRI and dynamic duplex ultrasound, which revealed compression of the axillary vein by a hypertrophic pectoralis minor muscle without thrombosis, constituting McCleery syndrome. This is a rare entity within the multiple thoracic outlet syndrome aetiologies. Taking a detailed history and physical examination complemented with diagnostic imaging are vital to the diagnosis. Afterward, the patient was treated with multimodal physical therapy and fully recovered and even exceeded his previous training and play level.

Cortical Hand Knob Paradoxical Thromboembolic Stroke in an Adolescent with Secundum Atrial Septal Defect and Paget-Schroetter Syndrome.

Venous thoracic outlet syndrome (vTOS) is an increasingly recognized diagnosis in young patients in which the subclavian vein is compressed within the costoclavicular space. With repetitive compression, thrombosis can develop and has been referred to as "effort thrombosis" or the Paget-Schroetter syndrome. Here, we present a 16-year-old boy with vTOS who presented with acute ischemic stroke (AIS) in the hand knob region of precentral gyrus due to paradoxical embolus in the setting of atrial septal defect.

Diagnosis and management of thoracic outlet syndrome in athletes.

The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use-related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.

Neurogenic thoracic outlet syndrome and controversies in diagnosis and management.

Compression of the neurovascular structures at the level of the scalene triangle and pectoralis minor space is rare, but increasing awareness and understanding is allowing for the treatment of more individuals than in the past. We outlined the recognition, preoperative evaluation, and treatment of patients with neurogenic thoracic outlet syndrome. Recent work has illustrated the role of imaging and centrality of the physical examination on the diagnosis. However, a fuller understanding of the spatial biomechanics of the shoulder, scalene triangle, and pectoralis minor musculotendinous complex has shown that, although physical therapy is a mainstay of treatment, a poor response to physical therapy with a sound diagnosis should not preclude decompression. Modes of failure of surgical decompression stress the importance of full resection of the anterior scalene muscle and all posterior rib impinging elements to minimize the risk of recurrence of symptoms. Neurogenic thoracic outlet syndrome is a rare but critical cause of disability of the upper extremity. Modern understanding of the pathophysiology and evaluation have led to a sounder diagnosis. Although physical therapy is a mainstay, surgical decompression remains the gold standard to preserve and recover function of the upper extremity. Understanding these principles will be central to further developments in the treatment of this patient population.

Exercise-induced venous thrombosis of the upper extremity: A case report.

Paget-Schroetter syndrome, the venous variant of thoracic outlet syndrome, is an uncommon presentation of deep vein thrombosis. In patients with Paget-Schroetter syndrome, the subclavian vein is compressed within the thoracic outlet as a result of repetitive and vigorous arm motions. Repeated endothelial injury leads to stasis in flow and eventual thrombus formation in the subclavian vein and its tributaries. This report highlights the case of an active and otherwise healthy 46-year-old patient who presented with swelling and pain of his right upper extremity after a run and was found to have multiple, effort-induced thrombi involving the right subclavian, axillary, brachial, and basilic veins. The unusual clinical picture of Paget-Schroetter syndrome and its presentation commonly in the demographic of young, healthy individuals make it a diagnosis likely overlooked and unfamiliar to many in the clinical setting.

Painful Raynaud's mimics.

Raynaud's syndrome is a common finding in many autoimmune conditions. Accurately diagnosing Raynaud's, and differentiating it from mimicking conditions, is imperative in rheumatologic diseases. Raynaud's syndrome and Raynaud's mimickers, especially painful Raynaud's mimickers, can prove a diagnostic challenge for the practicing rheumatologist. Painful Raynaud's mimickers can lead to increased patient stress and unnecessary medical work up; Healthcare providers need to be aware of Raynaud's mimickers when evaluating patient concerns of skin color changes and pain. The present narrative review aims to highlight Raynaud's syndrome, important painful mimickers that may be seen, diagnosis, and updated management recommendations.

A case of misdiagnosed arterial thoracic outlet syndrome as primary Raynaud's phenomenon.

Arterial thoracic outlet syndrome (aTOS) is a rare, but potentially, limb-threatening condition that is often misdiagnosed. We present the case of a 29-year-old man who was initially managed under the presumption of primary Raynaud's phenomenon for >1 year before the correct diagnosis of aTOS, and the delay in diagnosis was complicated by substantial distal thromboembolic occlusion. Successful staged treatment included thoracic outlet decompression, subclavian artery aneurysm repair with subclavian-to-axillary bypass, anticoagulation, and an unconventional axillary-to-ulnar artery bypass. This report highlights the diagnostic challenges of aTOS and the importance of considering it in patients with Raynaud's phenomenon and vaso-occlusive symptoms.

Scapular Elevation Sign - A New Sign in Evaluation of Thoracic Outlet Syndrome.

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic).

Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis.

BACKGROUND: Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. PURPOSE/HYPOTHESIS: The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. RESULTS: Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. CONCLUSION: The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.