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ORIGINAL ARTICLES
NUMBER 2-3 YEAR 2006
Thoracic Outlet Syndrome - Diagnosis and Therapy
1 Department of Cardiovascular Surgery, Institute of Cardiovascular Disease, Victor Babes University of Medicine and Pharmacy, Timisoara

Correspondence to: Prof. Ion Socoteanu, Institute of Cardiovascular Disease, 13A P.P. Carp Str.,
Timisoara, Tel. +40-0256-207355.
Email: isocoteanu@cardiologie.ro
REZUMAT
Introducere: Sindromul de apertura toracica superioara (S.A.T.S.) este un sindrom clinic complex determinat multifactorial de anomalii morfologice variate ale aperturii toracice superioare (A.T.S.). Aparent cu o incidenta rara, trece deseori necunoscut sau confundat, conducind la un diagnostic si tratament neadecvat urmat de complicatii grave, invalidante in evolutie, la bolnavi tineri. Material si metoda: Studiul cuprinde 20 de pacienti, tratati pentru S.A.T.S. in Clinica de Chirurgie Cardiovasculara Timisoara intre 1998 si 2004. Sunt prezentate aspectele clinice si angiografice, metodele terapeutice si rezultatele tratamentului. Rezultate: Simptomele de prezentare cele mai frecvente au fost anestezia (90%) si durerea (70%) la nivelul membrului superior. Structurile anatomice cel mai frecvent implicate in compresia vasculo-nervoasa au fost muschiul scalenic anterior si coasta cervicala. Dezobstructia cu sonda Fogarty pentru restabilirea fluxului arterial a fost aplicata in 5 cazuri, iar intr-un caz a fost necesar implantul de stent in artera subclavie. Nu s-au inregistrat lezari de plex brachial sau alte incidente intraoperatorii. in 17 cazuri simptomatologia a disparut, iar in 3 s-a ameliorat. Pulsul periferic a fost decelat postoperator la 17 cazuri. Durata medie de spitalizare a fost de 9 zile. Toti pacientii au fost externati vindecati chirurgical. Concluzii: Algoritmul terapeutic al S.A.T.S. poate fi eficient aplicat, inclusiv din punct de vedere chirurgical, de catre medici calificati, in institutii specializate. Rezultatele unei terapii adecvate, inainte de aparitia complicatiilor, sunt favorabile. Daca tratamentul este aplicat prea tirziu, dupa aparitia complicatiilor, eficienta acestuia scade, acesta fiind inca un argument in favoarea diagnosticului prompt si corect.

ABSTRACT
Introduction: The Thoracic Outlet Syndrome (TOS.) is a complex clinical syndrome determined by multiple factors, by various morphological abnormalities of the superior thoracic outlet (STO). Apparently characterized by a rare incidence, it often remains unidentified, leading to inadequate diagnosis and treatment and to serious complications, such as invalidity. Material and methods: We studied a number of 20 patients, treated for TOS in the Clinic of Cardiovascular Surgery of Timisoara between 1998-2004, regarding their clinical presentations, objective and angiographical signs, therapy method and results of the treatment. Results: The symptoms most frequently discovered in the studied patients were anaesthesia-90% and pain in the arm-70%. The anatomic elements most frequently involved in the compression of the vasculonervous complex were the fore scalenic muscle and the cervical ribs. In order to restore the normal arterial flow, deobstruction with Fogarty probe was applied in 5 cases, and in one case it was necessary to place a stent in the subclavian artery. A subclavian-axillary by-pass was necessary in two cases. There were no brachial plexus injuries or other intraoperatory incidents. In 17 cases the subjective symptomatology disappeared, and in 3 cases improved. The pulse was present in 17 cases and absent in 3 cases. The mean duration of hospitalization was 9 days. In all 20 cases the patients were cured at discharge. Conclusions: The therapeutic algorithm in TOS is well described and may be efficiently applied, by qualified doctors in adequate institutions. The results of the suitably applied therapy, before any complication appears, are always favorable. If the treatment is delayed until complications appear, it has less favorable results, which is another argument in the favor of a right and suitable diagnosis.
INTRODUCTION

The premise of the study is the situation in which a young patient presents with a symptomathology (angiologic, neurological, rheumatologic etc.) that solicits all these specialties, and sometimes an adequate solution is applied only in the phase of some invalidating complications.
The responsability of recognizing TOS falls both on the doctor who cures: avoiding confusions as it concerns the diagnosis and the therapeutic indication by finding the correct, clinical diagnosis, and the patient: recovering and avoiding severe complications.
The definition is clinical: TOS is a symptomatic complex, arterial, venous or neurologic or mixed, and causative - TOS is determined by the abnormalities of the superior thoracic outlet (STO) - cervical ribs, abnormalities of the first rib, abnormalities of the collarbone, the narrowing of the small pectoral space.

Figure 1. The sphere of the notion.
The history of TOS
Discoveries have gone through three stages: the first period - the period of the cervical ribs 1740-1920 (anatomic description - Gruber 1869; resection of the cervical rib - Cook 1861). The second period - the syndrome of the cervical rib without cervical ribs 1920-1956 (highlighting abnormalities of rib I, of the scalene muscle, of the collarbone, the small pectoral space in the pathogenesis of TOS; TOS causative terminology: scalenic syndrome, riboclavicular syndrome, syndrome of the first thoracic rib, hyperabduction syndrome) and the third period - the modern era of TOS - resection of the first thoracic rib, 1956 – present (TOS terminology through a clinical effect, Peet 1956, Rob 1958: arterial TOS, venous TOS, neurologic TOS, mixed TOS resection of the thoracic rib, Machleden histochemical microscopy - 1986; fore and medium scalenotomy, Sanders 1979).1-4
Regarding the nosology, in a larger classification, TOS belongs to the vasculonervous disturbances of the upper limb (degenerative, inflammatory, compressive, traumatic, embolic etc.). (Fig. 1)
In a more restricted classification, TOS is limited to disturbances produced through compression at the level of STO and is delimited, at the same time, from those produced through compression at the cervical level (e.g. S. Pancoast-Tobias) or those produced in a distal way by TOS.5,6

MATERIALS AND METHODS

Figure 2. Chart of comparison between the haphazard pathogenetic factors discovered in the studied patients (I: professions, II: wrong position [...]
Twenty patients were treated for TOS in the Clinic of Cardiovascular Surgery of Timisoara between 1998 and 2004.
Different elements of diagnosis have been followed: anamnestic (age, sex, haphazard pathogenetic factors), clinical, classic maneuvers of the scapular girdle and paraclinical (Doppler, cervical Rx, angiographic exploration). (Fig. 2) Three patients were admitted as emergencies, with signs of acute ischemia of the upper limb.
The indication for surgery was made respecting the criteria: symptoms (pain, swelling or heaviness decreased temperature, paresthesias) plus objective signs, static or dynamic (pallor or coolness, venous engorgement, cyanosis, gangrene of the digits).
The choice of the surgical treatment was made in accordance with STO morphopathology (decompression and revascularization procedures). For the resections of ribs our approach was mostly supraclavicular, but in the last years we have begun to use the transaxillary approach (5 cases). The clinical and paraclinical evolution were postoperatively followed in the period of hospitalization. The data was statistically processed using tables, comparison and distribution graphics, after the informed consent of the patients.

RESULTS

Anamnestic diagnosis data
The comparative distribution according to age groups of the presence of TOS in the lot of studied patients shows that TOS is dominant in active young ages.
The mean age of the patients was of 28.5 years. More than 80% was represented by the active, good for work age of 10 - 40 years.
Sex ratio: males/females = 7/13. TOS is more frequently found in women, a fact explained by the anatomic building of the scapular girdle (more fallen shoulders, less developed muscles of the scapular girdle, longer collarbone), the more frequent presence of the cervical rib, which could be interpreted as Adam’s rib, that the Bible speaks about.
Pathogenetic risk factors in the history are described in Figure 2.
In most cases, the risk factors proved to promote TOS. Their anamnestic highlighting is an important diagnostic element.

Clinical diagnosis data (Fig. 3)
Static signs: the symptoms most frequently discovered in the studied patients were anaesthesia - 90% and pain in the arm - 70%. Most often it is very difficult to specify the exact the etiology of these symptoms, which can be determined by neurological causes through the irritation of the sympathetic fibers of the brachial plexus and/or vascular causes. Necroses of the digits were found in 4 patients.
Dynamic signs: the classic maneuvers of the scapular girdle appeared as frequent as it is shown below: the test of the supraclavicular tenderness - 100%; Adson’s manoeuvre - 90%; Call manoeuvre -80%; the riboclavicular manoeuvre - 30%.
Figure 3. Comparative chart of the symptomatology discovered in the studied patients (I: paraesthesia, II: pain in the arm, III: pain in the sh [...]
Paraclinical diagnosis data
The Doppler ultrasound investigation, more sensitive in relation with the blood flow, spotlighted the fact that the flow was absent only in two of the five patients in which the absence of pulse had been detected through palpation.
Neck radiography: the cervical ribs have been discovered through cervical radiography in 13 patients, 9 from them presenting bilateral anomaly. Riboformal processes have been detected in 8 cases, but 4 of the cases also presented cervical ribs. Four patients presented compressive anatomic factors represented by structures (muscular-aponeurotic ones) that are not visible at a radiography.
Angiographic exploration: after the angiographic exploration, the following lesions given in Table 1 were discovered at the studied cases.

Therapeutic conduct
The anatomic elements most frequently involved in the compression of the vasculonervous complex were the fore scalenic muscle and the cervical ribs which, through division into sections and resection, freed the vasculonervous complex.
In several cases the resection of a part of the first thoracic rib was necessary-medium scalenotomy, and the small pectoral was sectioned in one case in which the disease had relapsed. In order to restore the normal arterial flow, deobstruction with Fogarty probe was applied in 5 cases, and in one case it was necessary to place a stent in the subclavian artery. A subclavian-axillary by-pass was necessary in two cases. (Table 2) There were no brachial plexus injuries or other intraoperatory incidents.
Table 1. Lesions discovered during angiographic exploration.
Table 2. Therapeutic conduct in the studied cases.


Postoperative results
A). Early results:
From a clinical point of view:
1) Subjective: in 17 cases the subjective sympto-mathology disappeared, and in 3 cases improved;
2) Objective: the pulse was present in 17 cases and absent in 3 cases.
From a paraclinical point of view the Doppler examination detected that the flow was present in 17 cases, and absent in 3 cases.
B). Results at discharge:
The mean duration of hospitalization was 9 days. The postoperative morbidity consisted mainly in wound pain and wound complications (hematoma, seroma) - 3 cases. In all 20 cases the patients were cured at discharge.
The follow up could not be made in all cases (from patient-related causes) and it is still in course, so we still don’t have statistically significant data about the long term evolution.

DISCUSSION

Incidence
Most authors agree that the incidence of TOS is 6-8%.
The relative incidence in the Clinic of
Cardiovascular Surgery of Timişoara is given in Table 3. The prevailing area of the activity of the clinic is cardiac surgery, so only a small part of it is actually related to vascular surgery, which explains the percentages in Table 1.
The real incidence is uncertain due to the confusion between TOS and rheumatic diseases, neurological diseases etc, or due to the underestimation of the symptomathology.7 This is obvious in the different statistics about TOS incidence reported by various hospitals and given in Table 4.
Table 3. TOS Incidence in the pathology of the Department of Cardiovascular Surgery Timisoara: 1998-2004.
Table 4. Real incidence of TOS

The reports in the literature about the results of the treatment TOS of are referring either to the TOS in general, either to one of the three types.
Etiopathogeny
Figure 4. STO with cervical rib.
a). Anatomic factors
Normally T.O.S includes the area crossed by the subclavian artery, the subclavian vein and the brachial plexus. They get out of the cervical region through the scalenic triangle, passing through the retroclavian fossa towards the axilla.
Pathological factors:
- Cervical rib; (Fig. 4)
- Abnormalities of the scalenic muscles: scars after lesions, variations of insertions, hypertrophy and spasm; the insertion of the back scalenic muscle between the fore and the middle scalenic muscles;11
- Abnormalities of the collarbone: position abnormalities, exuberant callus after fractures, defective consolidations, angulations, exostoses;
- Narrowed space of the small pectoral: the compression of the vasculonervous complex in the space of the small pectoral (between the coracoid apophysis of the scapula and the small pectoral muscle inserted on it) frequently appears in hyperabduction.12
b). Functional factors
Essential causes are the compression of the lumen of the subclavian artery, the irritation of the brachial plexus, the irritation of the sympathetic fibers, thromboses and embolism of the arteries, the compression of the lumen of the subclavian vein.
Hazard factors promoting TOS are repeated movements, straining of the upper limb, professions and jobs, sport activities.13-16

Physiopathology
The physiopathology of arterial and venous T.O.S is described in Figures 5 and 6 respectively.8,17
The physiopathology of neurologic TOS consists of disturbed functionality (the conduction speed of the nervous impulse decreases) and disturbed neuronal trophicity (reversible or irreversible degenerescence).18,19
TOS clinical features (Tables 5-8)
Although epidemiologically the neurological type of the TOS is more common (95%), and the arterial type is the least common (1-2% of the patients), following the venous type (3-4%), in our practice, probably biased by the specialty of the department (cardiovascular surgery) we treated more frequently the arterial type, sometimes the acute onset, with thrombosis, combined with, in the majority of cases, the neurological type (as it results from the prevalence of pain and anesthesia as presenting symptoms) .
Figure 5. The physiopathology of the compression of subclavian artery.
Figure 6. The physiopathology of the compression of subclavian vein.

Table 5. Arterial TOS clinical features.9,20
Table 6. Venous TOS clinical features.8,21

Table 7. Neurologic TOS clinical features.22,23
Table 8. Mixed TOS clinical features.

Figure 7. Angiographic image of an occluded subclavian artery in TOS
Investigations
Noninvasive explorations: measurement of the blood pressure, chest radiography, Doppler ultrasond exploration, color Doppler sonography, magnetic resonance imaging (MRI), tomodensimetry (TC), pletismography; EMG, study of the conduction of the nervous speed.
Invasive explorations: arteriography, cineangio-graphy, angioscopy, exploration with isotopes, phlebography, radioisotopic venography with Tc99.24,25
Limited by the possibilities of our cardiological department, we used only handheld Doppler and angiography as explorations. (Fig. 7)

Therapy (Tables 9,10)
Over six years, Edwards et all performed 52 rib resections in 46 patients, and 42 patients (48 resections) showed immediate improvement in symptoms following surgery, although symptoms recurred in three patients between 6 and 8 months post-operatively.29 Yavuzer after operating on 127 patients with TOS, with a favorable surgical outcome of 82.7%, concluded that the shorter duration of symptoms and the presence of a cervical rib had a significantly unfavorable effect on the surgical outcome.30 A study comprising 55 operations (mostly first - 59.6% and cervical costae - 21.3% resections) performed on 47 patients (89.3% neurological TOS, 10.7% vascular) by Balci et al showed an improvement of 75% for the lower plexus and 50% for the upper plexus compressions, at a follow-up of 4.6 years.31
Cervical and first costae resections were frequently used, because of the predominance of arterial lesions (patients presented in a later phase of their evolution, with morphologic modifications of the artery) and neurological symptoms (with the need of neural decompression).
Table 9. Therapy of TOS8,26-28
Table 10. Indications for surgical therapy of TOS5
Cervical and first costae resections were frequently used, because of the predominance of arterial lesions (patients presented in a later phase of their evolution, with morphologic modifications of the artery) and neurological symptoms (with the need of neural decompression).
Sanders, with a large experience of treating 5000 with TOS, observed that only 30% had requiered surgery, the rest improving with physical therapy; also, the improvement rate of surgery depended on the cause of TOS (a success rate of 80-85% for auto injuries and 60-70% for repetitive stress at work).32 The work injuries seems to be a common cause of TOS in the western world (probably in our country it is the same situation, but it is poorly recognized): from the 158 injured workers in the Washington State Workers’ Compensation system who received TOS surgery during 1986 to 1991 sixty percent of workers were still work disabled 1 year after surgery, and compared with a nonsurgical sample of TOS patients, those receiving surgery had 50% greater medical costs and were three to four times more likely to be work disabled.33,34
The most severe presentation of the arterial TOS is the acute ischemia, caused by thrombosis and embolism. In this case, the goals of the treatment include the restoration of perfusion to the distal extremity (eg, with thromboembolectomy), the repair of the anatomic anomaly causing the narrowing of the thoracic outlet, and the reconstruction of the arterial segment in the thoracic outlet.
It is still in debate the role of angioplasty and thrombolysis versus that of surgery in a patient with acute symptoms of arterial thoracic outlet syndrome. In a review of 137 patients by Sanders, 84% of patients had successful results after surgical treatment.35 Hood et al reported the results in 3 patients with acute upper extremity emboli. Two of these patients received thrombolytic therapy and were without symptoms after 22-month follow-up.36
The percutaneous transluminal angioplasty can be used, especially in patients who are poor surgical candidates or in patients with mild arterial symptoms. Farina et al compared the outcomes for proximal subclavian angioplasty with those for surgical carotid-subclavian reconstruction: the patency rates for angioplasty progressively decreased from an initial rate of 91% to 54% at 5 years, but the rates for surgical reconstruction remained unchanged at approximately 86%.37 Korner reported a secondary cumulative patency rate of 72% after 100-month follow-up in 28 patients who underwent subclavian and innominate angioplasty.38
Patients with primary venous thrombosis are treated best with catheter-directed thrombolysis and mechanical thrombectomy, followed by surgical thoracic outlet decompression, with an average success rate of 81%.39 Kreienberg et al treated 23 patients with thrombolysis, followed by immediate (within 24 h) surgical thoracic inlet decompression and then angioplasty within 24 hours. All the veins treated with angioplasty were patent at a mean follow-up of 4 years, and of those additionally treated with stent placement, 9 were patent at a mean follow-up of 3.5 years.40
The stent placement without surgical de-compression is not recommended because the stent may be compressed or be fractured by the thoracic outlet, as in the Meier’s study, when the two patients who underwent immediate stent placement and did not undergo immediate surgical rib resection had the complication of stent fracture.41
Comparing our results to those from the literature, even though the results presented upwards are so heterogeneous (because of the relative rarity of the disease, the various forms of disease and types of treatments) and we can not do a rigorous comparison, and despite of the limitation of the study (a few cases, because of the short period of time and the specificity of the surgery department, not only vascular, but also cardiac) we can observe that the outcomes are similar, and the large range of treatment methods for TOS are applied also in our department, with a comparable success.

CONCLUSIONS

TOS has a very complex and varied symptomatology, sometimes with some prevalent features (arterial, venous, neurologic, mixed), but often deceiving, leading to wrong diagnoses.
TOS imposes a correct and early diagnosis, taking into account the fact that it affects especially young patients.
TOS can be quite easily detected when the doctor has minimum knowledge about TOS and makes a complete static and dynamic clinical examination, complementary tests being accessible and convincing.
The therapeutic algorithm in TOS is well described and may be efficiently applied, including a surgical point of view, by qualified doctors in adequate institutions.
The results of the suitably applied therapy, before any complication appear, are always favorable, immediately and in the subsequent evolution.
If the treatment is applied too late, after the complications already appeared, it has less favorable results, which is another argument in favor of a right and suitable diagnosis.
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