Arterial Thoracic Outlet Syndrome Presents with Acute Ischemia in Young Women

Objective(s): Despite that thoracic outlet syndrome (TOS) has been well-described in the literature, limited studies have focused on arterial TOS, since it was previously thought to occur in less than 1% of patients with TOS. In our practice, arterial TOS is presenting more commonly and this study reviewed our experience with arterial TOS to determine symptoms at presentation, optimal surgical approach and outcomes following intervention.
Methods: A retrospective review of 168 patients with TOS referred to our tertiary care center between 2003-2007 was performed. Patients with arterial TOS, as diagnosed by ultrasound, CT, MRI and angiography were reviewed for pre-operative symptoms, surgical technique and complications post-operatively.
Results: Seven of the 168 patients (4.2%) with TOS had an arterial etiology. These patients ranged in age from 12 to 49 years (mean 29 years), and demonstrated a strong female predilection (71%). Acute ischemic symptoms were the initial presentation in 71% (5/7). All arterial TOS patients had associated bony abnormalities. Among the arterial TOS patients, 57% (4/7) had bilateral abnormalities. Of the 6 patients who did not need arterial replacement, all underwent the transaxillary surgical approach to remove their first rib, cervical rib and/or rudimentary first rib. The one patient that required a saphenous vein interposition graft for a subclavian-axillary aneurysm underwent a supraclavicular approach. All patients did well post-operatively with only one patient developing a hematoma. Additionally, there were no brachial plexus abnormalities following repair. Mean follow-up was 40 weeks (range 8-119 weeks). (Table 1)
Conclusions: Arterial TOS occurs more frequently than previously described and severe symptomatic ischemia is frequently the initial presentation. All patients with arterial TOS have associated bony abnormalities. Unless arterial reconstruction is needed, arterial TOS patients can undergo a transaxial surgical approach, as it is safe and offers the advantage of improved cosmesis in this young, predominantly female population.