13: THORACIC OUTLET SYNDROME AND ARTERIAL ANEURYSM OF UPPER EXTREMITY Irina Shakhnovich View Full Chapter Figures Only Tables Only Videos Only Print Share Email Send Email Your Name (required) ! Example: John Doe Email Address (required) ! Please enter a valid sender email address. Example: email@example.com CC Me Recipient Email Address (required) ! Separate multiple email address with semi-colons (up to 5). Subject Subject for your email. Message (Maximum characters: 1,000) Please enter your name Please enter your email address Please enter a valid recipient email address. Example:firstname.lastname@example.org Thank you! Your email has been sent to: The recipient(s) will receive an email message that includes a link to the selected article. Recipients may need to check their spam filters or confirm that the address is safe. Return to: Send Another Email An error has occurred sending your email(s). Please try again later or contact an administrator at OnlineCustomer_Service@mheducation.com. Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Shakhnovich I. Shakhnovich I Shakhnovich, Irina.THORACIC OUTLET SYNDROME AND ARTERIAL ANEURYSM OF UPPER EXTREMITY. In: Dean SM, Satiani B, Abraham WT. Dean S.M., Satiani B, Abraham W.T. Eds. Steven M. Dean, et al.eds. Color Atlas and Synopsis of Vascular Diseases New York, NY: McGraw-Hill; 2014. http://accesssurgery.mhmedical.com/content.aspx?bookid=1201§ionid=71013049. Accessed April 20, 2018. MLA Citation Shakhnovich I. Shakhnovich I Shakhnovich, Irina.. "THORACIC OUTLET SYNDROME AND ARTERIAL ANEURYSM OF UPPER EXTREMITY." Color Atlas and Synopsis of Vascular Diseases Dean SM, Satiani B, Abraham WT. Dean S.M., Satiani B, Abraham W.T. Eds. Steven M. Dean, et al. New York, NY: McGraw-Hill, 2014, http://accesssurgery.mhmedical.com/content.aspx?bookid=1201§ionid=71013049. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager Mendeley © Copyright Tools Search Book Top Return Clip Autosuggest Results + PATIENT STORY Print Section ++ ++ A 20-year-old woman presented to the emergency room with sudden onset of cold, pale fingers, and discolored spots in the fingertips of the left hand (Figure 13-1). The patient's medical history was significant for fatigue and weakness of the left hand for about 1 year. She attributed these symptoms to overuse at work as a nursing assistant at the hospital. Her physical examination was significant for discoloration and splinter hemorrhages of the fingers. She had palpable radial and ulnar pulses. With overhead left arm elevation, the patient complained of pain in the entire left upper extremity. The workup included a chest x-ray and left upper extremity angiogram. The chest x-ray showed bilateral cervical ribs (Figure 13-2). Angiogram confirmed the presence of a subclavian artery aneurysm with partial thrombosis (Figure 13-3). Her hand angiogram showed evidence of embolic disease to her digits (Figure 13-4). ++ FIGURE 13-1 Patient's hand with evidence of digital ischemia manifested by splinter hemorrhages at the fingertips. Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ FIGURE 13-2 Chest radiograph demonstrates bilateral cervical ribs (arrows). (By permission from Upper extremity arterial disease. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier Inc; 2010:1901.) Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ FIGURE 13-3 Left subclavian arteriogram demonstrating a subclavian artery aneurysm (red arrow) and partial thrombus (blue arrow). Also note the presence of multiple collateral vessels, confirming the presence of chronic disease. (By permission from Upper extremity arterial disease. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier Inc; 2010:1901.) Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ FIGURE 13-4 Hand angiogram demonstrating distal embolization in the fingers (arrows). (By permission from Upper extremity arterial disease. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier Inc; 2010:1901.) Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ The final diagnosis was of thoracic outlet syndrome (TOS) with arterial involvement complicated by subclavian arterial aneurysm and distal microembolization. + EPIDEMIOLOGY Print Section ++ ++ Arterial involvement is the least common form of TOS. Most patients with symptoms of arterial TOS are young, active adults. The mean age in most published series is 37 years, with a similar proportion of men and women reported.1 The condition appears to be related to bony abnormalities or trauma in nearly every circumstance. No familial predisposition has been described.1 + PATHOPHYSIOLOGY Print Section ++ ++ The compression of the subclavian artery caused by the cervical rib leads to turbulent blood flow through the narrowed segment of the artery. This type of long-standing stress eventually results in degeneration of the arterial wall, and the poststenotic dilatation then leads to formation of an aneurysm in the location of the artery immediately beyond the stenosis. Arterial complications of TOS are associated with bony abnormalities in almost all cases. Cervical ribs that cause subclavian artery damage tend to be short, broad, and complete, and usually articulate with the first rib as a pseudarthrosis.2 Less common causes include hypertrophic callus from a healed clavicle fracture, anomalous first ribs, and fibrocartilaginous bands associated with the anterior scalene muscle.3 The most common manifestation is hand ischemia as a result of microembolization. However, arterial TOS can be associated with less dramatic symptoms and may go unrecognized because it tends to occur in young patients without a history of atherosclerotic risk factors.1 + DIAGNOSIS Print Section ++ ++ Arterial TOS is a clinical diagnosis and is made by combining important elements from the history and physical examination. The following studies are important adjuncts that may support the diagnosis and rule out other causes of upper extremity ischemia. ++ Compression maneuvers can be used to help with the diagnosis of TOS. But none of these techniques are accurate. For example, the Adson test consists of having the patient elevate his or her chin and turn it to the affected side. Disappearance or reduction of the radial pulse with this maneuver is considered a positive test result. This finding has not proved to be diagnostic of TOS. The incidence of false-positive results in normal, healthy volunteers ranges from 9% to 53%.4 Yet, a negative test result may be helpful in ruling out the diagnosis and prompting evaluation for an alternative cause. Duplex ultrasonographic examination of the subclavian and axillary arteries may demonstrate aneurysmal changes or elevated flow velocities correlating with a compressive stenosis. This may facilitate rapid diagnoses. Radiographic imaging Chest radiographs with cervical spine views can demonstrate bony pathology. Cervical ribs and large clavicle fracture calluses are easily seen on plain films (Figure 13-2). Anomalous first ribs are more difficult to detect and may require other imaging modalities.3 Catheter-based angiography of the upper extremity arteriography is the gold standard for evaluation of arterial TOS. This is an important test in operative planning for localization and character of arterial compression. An arteriogram also visualizes the extent of arterial damage and permits evaluation of the distal circulation. Computed tomography with intravenous contrast-enhanced angiography is an accurate study and an acceptable substitute for invasive angiography. It is gradually replacing catheter-based arteriography in many centers. However, arteriography with magnified views remains the best method for demonstrating embolic occlusion of the small arteries of the hand and fingers (Figure 13-4).1 + DIFFERENTIAL DIAGNOSIS Print Section ++ ++ Other causes of upper extremity ischemia may be suspected and need to be ruled out with laboratory studies and imaging studies, as discussed below. ++ A history of cardiac arrhythmia such as atrial fibrillation can suggest a cardioembolic etiology. These patients need to be evaluated with surface cardiac echo and bubble study. Personal or a family history of venous thromboembolic disease suggests an underlying hypercoagulable state. Further hypercoagulable workup is strongly recommended. Patients with risk factors for atherosclerosis, particularly patients with a history of heavy tobacco use, suggests the possibility of atherosclerotic occlusive disease as the etiology. Evaluation for connective tissue disease is suggested for patients with dermatitis and any esophageal dysmotility. Associated symptoms of polymyalgia rheumatica suggest the possibility of vasculitis.1,2, and 3 Arterial dissection, radiation injury, and trauma can cause microembolization and can be easily detected with imaging studies such as computed tomographic angiography (CTA) or catheter-based angiography. + MANAGEMENT Print Section ++ ++ Medical Treatment ++ There is no role for nonoperative treatment of symptomatic patients with arterial TOS, although it may be appropriate for some asymptomatic patients. Natural history of asymptomatic disease is unknown, and close follow-up is strongly recommended. ++ Surgical Treatment ++ The three main components of treatment include relieving the arterial compression, removing the source of embolus, and restoring the distal circulation. Relieving the arterial compression involves resection of cervical ribs and any other identified anomalies causing impingement in the thoracic outlet. This is performed through a supraclavicular incision, through which the cervical rib and the first rib are identified, divided, and removed. If subclavian reconstruction is planned, the suitable length of the normal artery is identified and adequately mobilized. The diseased segment of the artery is removed and an interposition bypass graft is constructed in an end-to-end fashion. The best conduit for the subclavian artery is debatable, and both prosthetic bypass graft and autologous vein can be used. The success of arterial reconstruction is usually related to the status of the arterial outflow in the limb. Restoring the distal circulation may involve any combination of thrombolysis, thromboembolectomy, or bypass.5 + FOLLOW-UP Print Section ++ ++ Successful outcome of the surgery is determined by relief of symptoms, patency of arterial bypasses, and limb salvage. Published case series report completes relief of symptoms in more than 90% of patients.6 Long-term results are related to the status of the distal vasculature. Limbs with compromised outflow secondary to embolization have a poor prognosis. + REFERENCES Print Section ++ +1. +Smith ST, Valentine RJ. Thoracic outlet syndrome: arterial. In: Cronenwett JL, Johnston, KW, eds. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier; 2010:1899–1906. +2. +Green RM. Vascular manifestations of the thoracic outlet syndrome. Semin Vasc Surg. 1988;11:67–76. +3. +Durham JR, Yao ST, Pearce WH et al.. Arterial injuries in the thoracic outlet syndrome. J Vasc Surg. 1995;21:57–70. +4. +Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med. 1998;5:337–342. +5. +Nehler MR, Taylor LM, Moneta GL, Porter JM. Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg[Archives of Surgery Full Text]. 1997;132:527–532. +6. +Cormier JM, Amrane M, Ward A et al.. Arterial complications of the thoracic outlet syndrome: fifty-five operative cases. J Vasc Surg. 1989;9:778–787.