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2.1 Guidelines
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– Results of thrombolysis.
– Any complications.
• Operative thoracic outlet decompression or venous intervention.
– Duration of symptoms in days and classication as before.
– Whether the patient has received thrombolysis before surgery and results
thereof. If so, interval in days between the cessation of thrombolysis and
surgery.
– Status of the subclavian vein at the time of operation.
– Surgical approach and structures removed.
– Presence or absence of occult anterior rst rib fracture or osteophytic
degeneration.
– Use of external axillary-subclavian venolysis and status of vein thereafter.
– Whether any adjunctive procedures were performed.
Intraoperative venography.
Endovenous intervention.
Surgical repair of the subclavian vein, including details of repair and material used.
Other reconstruction (jugular turndown, arteriovenous stula creation).
– Pleural entry, use of chest drainage.
– Intraoperative complications.
– Postoperative pain control and methods used.
– Length of hospital stay.
– All postoperative complications or readmissions within 30days.
– Postoperative anticoagulation or antiplatelet therapy, with duration.
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ATO S
Description of treatment should be categorized into the three goals of treatment for
patients with ATOS:
1. repair/replacement of the damaged subclavian artery (local disease);
2. correction of the original inciting cause at the thoracic outlet (cause); and
3. correction of any distal embolic or other problems (distal disease).
As many details as possible should be documented:
• Catheter-directed thrombolysis.
– Any endovascular intervention done at this time should be recorded.
– Any complications should be recorded.
– Status of arm and hand at cessation of lysis should be recorded.
• Operative management.
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– Whether the patient has received thrombolysis before surgery. If so, interval
(in days) between cessation of thrombolysis and surgery.
– Status of the artery at the time of operation (at scalene triangle and in arm).
– Surgical approach and structures removed.
– Whether any adjunctive procedures were performed.
Endoluminal intervention.
Arterial repair, replacement, or bypass.
[For either, conduit or material used]
Distal embolectomy.
Fasciotomy.
– Completion arteriography or duplex ultrasound.
– Neurological status before and after surgery.
– Pleural entry, use of chest drainage.
– Intraoperative complications.
– Postoperative pain control methods used.
– Length of hospital stay.
– All postoperative complications or readmissions within 30days.
2 Thoracic-Outlet-Syndrome
2.1.2 American College ofRadiology Appropriateness Criteria
The American College of Radiology has published criteria for appropriate imaging
in NTOS, VTOS and ATOS [3].
• Radiography of the chest and either MRI without and with IV contrast of the
chest or MRI without IV contrast of the chest are usually appropriate for the
initial and follow-up imaging after surgery or intervention for patients with NTOS.
• Radiography of the chest and US duplex Doppler of the subclavian artery and
vein, CT with IV contrast of the chest, or catheter venography of the upper
extremity are usually appropriate for the initial and follow-up imaging after surgery or intervention for patients with VTOS.
• Radiography of the chest and CTA with IV contrast of the chest, MRA without
and with IV contrast of the chest, US duplex Doppler of the subclavian artery and
vein, or arteriography of the upper extremity are usually appropriate for the initial and follow-up imaging after surgery or intervention for patients with ATOS.
2.2 Results
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2.2 Results
2.2.1 Meta-Analyses/Systematic Reviews
2.2.1.1 Surgical Procedures forNTOS
In a systematic review, Yin et al. [4] compared the treatment outcomes of three
alternative surgical procedures for NTOS: transaxillary rst rib excision, 17 studies/
supraclavicular rst rib excision with scalenectomy, 9 studies/and supraclavicular
release leaving the rst rib intact, 14 studies. In this analysis, supraclavicular relase
had the highest point estimates of success rate and complete relief rate (85% and
61%, respectively), followed by supraclavicular rst rib excision (77% and 57%,
respectively) and transaxillary rst rib excision (76% and 53%, respectively). The
probabilities of complete relief rate of 50% or greater were 67%, 71%, and 69% for
transaxillary rst rib excision, supraclavicular rst rib excision, and supraclavicular
release, respectively. Sensitivity analyses showed similar results. The complication
rates for transaxillary rst rib excision, supraclavicular rst rib excision, and supraclavicular release were, respectively, 22.5%, 25.9%, and 12.6%. These ndings suggest that resection of the rst rib is not necessary for surgical treatment of patients
with neurogenic TOS.
In a second meta-analysis, Blondin etal. [5] came to a similar conclusion: rib-
sparing scalenectomy (RSS) is an effective option for the treatment of NTOS, RSS
is sufcient for treating NTOS without the added morbidity of rst rib resection.
2.2.1.2 Procedures forPaget-Schrötter Syndrome (VTOS)
For a meta-analysis on the treatment of Paget-Schrötter syndrome, Karaolanis etal.
[6] found 25 studies with 1511 patients. Thrombolysis was performed in 1177
(77.9%) patients, anticoagulation in 658 (43.5%) and decompression of the thoracic
outlet in 1293 (85.6%). The complete thrombus resolution was estimated at 78.1%
after thrombolysis, and the respective pooled proportion for partial resolution of
thrombus was 23.7%. Despite thrombolytic therapy, additional balloon angioplasty
was performed in 212 patients for residual stenosis, although only 36 stents were
implanted. After anticoagulation, complete thrombus resolution was seen in 40.7%
and partial resolution in 29.1%. During follow-up, 51.75% of patients with any
initial treatment modality had no remaining thrombus and 84.7% of these patients
were free of symptoms. A subgroup meta-analysis with 20 studies and 1309 patients,
showed signicantly improved vein patency and symptom resolution in patients
who had rst rib resection with or without venoplasty, compared with those who
had only thrombolysis. The data suggest that resection of the rst rib after thrombolysis is the treatment of choice in the majority of patients with Paget-Schrötter
syndrome.
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2 Thoracic-Outlet-Syndrome
2.2.2 Studies
2.2.2.1 TOS: Incidence/Registry Data
Based on a prospectively maintained database of an academic TOS centre with 526
admitted patients in 47months, Illig etal. [7] reported the ratio of NTOS, VTOS
and ATOS in the admission diagnoses as 82%, 16% and 2%, respectively. NTOS
was also the TOS most commonly treated surgically (73%, 25%, 3%). They estimated the annual incidence of NTOS to be approximately 3 cases/100,000 population, and that of VTOS to be 1/100,000. Although TOS is considered a rare disease,
the incidence according to this calculation was not lower than that of amyotrophic
lateral sclerosis, for example.
George etal. [8] analysed 3547 TOS operations recorded in the National Inpatient
Sample for the years 2010 to 2015 (89.2% NTOS, 9.9% VTOS and 0.9% ATOS).
They estimated that a total of 18,210 TOS surgeries were performed in the US during this time, with an upward trend. Higher volume centres (≥10 cases/year) represented 5.2% of hospitals, but 37% of cases, and achieved signicantly lower overall
major complication rates, but no difference in neurologic complications. Overall
mortality was less than 0.6% and was highest after procedures for VTOS (4.2%),
followed by 0.2% for NTOS and 0% for ATOS. Neurological complications
occurred in 0.34% of cases, brachial plexus injuries in 0.11%, iatrogenic pneumothorax in 3.3% and vascular complications in 8.7% in VTOS, 9.7% in ATOS and
only 2.1% in NTOS.Higher volume centers delivered higher value care: less or
similar operative morbidity with lower total hospital charges.
In a retrospective analysis of the National Surgical Quality Improvement Program
database from 2005 to 2014, Jubbal etal. [9] found 1853 patients with TOS.The
purpose of this study was to identify the most common techniques used to treat TOS
and compare complication rates. The most common procedures were rst rib resection (64%), followed by anterior scalenectomy with cervical rib resection (32.9%),
brachial plexus decompression (27.2%) and anterior scalenectomy without cervical
rib resection (8.9%). The authors reviewed complication rates and concluded that
surgical treatment of TOS most commonly involves rst rib resection, which is not
associated with an increased risk of medical or surgical complications. Factors that
demonstrated association with medical complications included female gender, ASA
classication of 3 or greater, and prolonged operative time. No factors demonstrated
statistically signicant association with surgical complications.
2.2.2.2 VTOS: Outcome
The outcome in 36 patients with chronic VTOS was presented by Pesser etal. [10].
VTOS was considered chronic when symptoms and venous stenosis or occlusion
were present for >3 months after the initial primary upper extremity deep vein
thrombosis event. Treatment algorithm consisted of transaxillary rst rib resection
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39
for thoracic outlet decompression, external venolysis, and intraoperative venography, followed by percutaneous low-pressure diagnostic balloon ination, in a single
setting. Chronic occlusions that could not be recanalized with a guidewire were
excluded. At a mean follow-up of 24months, 83% of patients were free of symptoms. The functional outcome measures and quality of life had all improved signicantly (P< .01). A return to daily activities was achieved by 93% of the patients.
The treatment of patients with chronic venous thoracic outlet syndrome using a
same admission treatment algorithm consisting of transaxillary thoracic outlet
decompression, external venolysis, and percutaneous transluminal angioplasty is
effective and leads to signicant improvement in functional outcome and physical
quality of life.
Another case series on patients with VTOS included 15 patients each with supra-
clavicular and 15 patients with infraclavicular decompression [11]. Infraclavicular
thoracic outlet decompression was associated with fewer patients with postoperative symptoms, 0 of 15 (0%) versus 8 of 15 (53.3%), (P=0.0022), and infraclavicular thoracic outlet decompression demonstrated improved patency, 15 of 15 (100%)
versus 8 of 15 (53.3%), (P = 0.028) at a mean combined follow-up of
8.47±10.8months.
The supraclavicular approach was also compared with the infraclavicular
approach in patients with VTOS by Dua et al. [12]. 109 rib resections were performed, 54 via a supraclavicular and 55 via an infraclavicular approach. There was
a signicant decrease in the number of complications in the infraclavicular cohort
compared with the supraclavicular group, but the long-term outcomes in terms of
venous patency and quality of life did not differ between the two groups. Dua etal.
[13] also reported long-term functional outcomes in 170 patients with 188 rib resections for all forms of TOS (102 NTOS, 82 VTOS, 4 ATOS) with a mean follow-up
time of 5.3years. 167 (88.9%) patients returned to baseline activities postoperatively, this included active athletes, and 96% of patients stated they were satised
and would undergo the procedure again.
Silverberg etal. [14] chose a different approach. They reported the long-term
results in 18 patients with Paget-Schrötter syndrome who were treated exclusively
with anticoagulation and catheter-directed thrombolysis (up to 72h) without surgical management. Patients excluded were those with a clinical presentation exceeding 14days from the development of symptoms to hospital admission and patients
with an existing contraindication to thrombolysis. After thrombolysis, the treated
veins were found to be patent on venography in 16 of 18 patients. Two patients had
occluded subclavian/axillary veins. All patients with successful catheter-based
thrombolysis were found to have focal stenotic lesions in the subclavian vein; PTA
was performed in only 4 patients with high-grade stenosis >80%. After thrombolysis, patients were anticoagulated for a mean of 26 months. Mean time from the
index event to the follow-up clinic visit was 109 (37–176) months. 17 patients
(94%) had a Villalta score of 0–3, equivalent to non-existent post-thrombotic syndrome. 14 patients (78%) were completely asymptomatic. None of the patients suffered from impaired quality of life. The study demonstrates that patients with
Paget-Schroetter syndrome treated with catheter-directed thrombolysis and
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2 Thoracic-Outlet-Syndrome
anticoagulation, but no rib resection did not develop post-thrombotic syndrome and
did not suffer from an impaired quality of life.
2.2.2.3 NTOS: Outcome
Balderman etal. [15] assessed the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic
thoracic outlet syndrome (NTOS) using patient-reported outcomes measures.
During a median follow-up >12 months of 130 patients with NTOS, 40 (31%)
obtained symptom improvement with physical therapy alone and 90 (69%) underwent surgery. Surgery for NTOS consisted of supraclavicular decompression (with
complete anterior and middle scalenectomy, rst rib resection, and brachial plexus
neurolysis) or subcoracoid decompression (pectoralis minor tenotomy), or both.
Patients rated the outcome after surgery as excellent in 27%, good in 36%, fair in
26% and poor in 12%. Despite substantial pretreatment disability, surgery for NTOS
can be effective when physical therapy is insufcient, with substantial symptom
improvement in approximately 90% of patients. These outcomes were reected by
changes in Disability of the Arm, Shoulder, and Hand scores, but no specic factors
predicted which patients will benet from physical therapy alone or will require
surgery.
The rst single centre prospective cohort study to describe the implementation of
a multidisciplinary diagnostic care pathway for patients with NTOS based on the
SVS reporting standards was published by Pesser etal. [16]. NTOS was diagnosed
in 476 of 856 (55.6%) referred patients. Dedicated physiotherapy as the primary
treatment was successful in 186 patients (39.1%). Surgical treatment was performed
in 290 (60.9%) patients, of whom 274 were included in the follow up (mean follow up 16.9±9.2months). Surgical treatment consisted of thoracic outlet decompression, which included a complete resection of the rst rib, partial anterior and medial
scalenectomy and a thorough neurolysis of the branches of the lower brachial
plexus. At follow-up, surgical outcome was considered excellent in 83 patients
(30.3%), good in 114 (41.6%), fair in 43 (15.7%) and poor (recurrent or persistent
NTOS) in 34 (12.4%). The results suggest a prominent role for multidisciplinary
care pathways in NTOS diagnostics, underline the role of dedicated physiotherapy
as the primary treatment, and show good to excellent short term treatment outcomes
in the majority of the surgically treated NTOS patients following previous unsuccessful physiotherapy.
Johansen [17] questioned the indication for rst rib resection in NTOS. He
reported on a retrospective series of 504 thoracic outlet decompression procedures
in 442 patients with scalene block-proved neurogenic thoracic outlet syndrome.
Patients underwent anterior, middle and minimus scalenectomy and brachial plexus
neurolysis via a supraclavicular incision, combined with pectoralis minor tenotomy
through a small vertical infraclavicular incision. No rst ribs were excised, and all
procedures were performed by a single surgeon. All patients had a positive preoperative response to scalenus blockade using local anaesthetic. The average operative
2.2 Results
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time was 1.15h, and the average length of stay was 1.05days. Major complications
(intraoperative arterial injury, wound haematoma requiring reoperation, and chylothorax) were seen in 7 patients (1.4%). All but two patients (99.6%) had symptomatic improvement, with 90.9% experiencing ≥50% improvement in preoperative
symptoms and function. These results make it questionable whether the rst rib
should actually be resected in NTOS.
Ruopsa etal. [18] also pointed out that rib resection was probably unnecessary
in most of their patients with NTOS. They reported long-term outcomes in 94
patients with NTOS and scalenectomy with a mean follow-up of 12.9years. 82% of
women and 57% of men reported that aid from surgery had been excellent or good.
69% reported that surgery helped considerably for at least a mean of 9.9years. The
weak point of this study is the fact that of 210 patients operated on, only 94 (47%)
ultimately accepted the invitation for a follow-up examination.
The learning curve for supraclavicular thoracic outlet decompression with rst
and/or cervical rib resection of a single surgeon was reported by Panda etal. [19].
Indication was an NTOS.The mean operative time was 201.5 (SD 56.7) minutes for
114 patients. A plateau was reached after 45 to 55 operations. The operative times
before and after the rst 51 operations (rst and second collectives) were 231.1
(213.6–248.6) vs. 178.3 (168.4–188.3) minutes (p<0.001). There were no signicant differences between the two groups regarding the length of postoperative stay,
duration of closed-suction drainage, and frequency of complications. At follow-up
after a mean of 90days, patients in both the early and late cohorts reported a signicant improvement in their symptoms (74% vs. 73%). Certain preoperative considerations (ASA classication and failed preoperative botulinum injection) were
associated with minimal improvement in postoperative symptoms.
Goeteyn etal. [20] highlighted the controversial surgical treatment of NTOS and
conducted the rst (small) randomised trial to objectify the effect of thoracic outlet
decompression (TOD). Patients with a diagnosis of NTOS refractory to conservative therapy were randomised to one of two intervention arms, receiving either a
transaxillary thoracic outlet decompression (complete resection of the rst rib and
partial scalenus resection) (n=25) or continued conservative treatment (n= 25).
After 3 months, the conservative treated group was also offered a transaxillary thoracic outlet decompression. The primary outcome was change in the Disability of
the Arm, Shoulder and Hand (DASH) questionnaire score. At 3months, there was a
statistically signicant difference in DASH scores (transaxillary decompression
mean 45.15, conservative treatment 64.92; p<0.001). All patients in the conservative treatment group applied for surgery 3 months after randomisation. After surgery
of the conservative treatment group, there was no statistically signicant difference
between the groups for all primary and secondary outcome measures. The conclusion was that surgical thoracic outlet decompression is effective in improving symptoms in patients with NTOS who do not respond to conservative treatment.
In addition, Goeteyn etal. [21] reported the results of redo thoracic outlet decom-
pression surgery through the supraclavicular approach for persistent or recurrent
NTOS.Recurrent NTOS was assumed to occur when symptoms reappeared after an
initial successful period following a rst thoracic outlet decompression. The redo
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2 Thoracic-Outlet-Syndrome
procedure consisted of complete (cartilage-cartilage) resection of the rst rib, any
bony and brous anomalies, complete anterior and middle scalenectomy, and complete neurolysis of the brachial plexus (complete anatomical decompression of the
brachial plexus). In total, 45 patients had redo surgery. Postoperative complications
were seen in eight patients (18.18%). One patient had postoperative complications
with permanent impairment (Horner syndrome). Seven patients had postoperative
complications with full recovery (three patients had a chylous leakage that was
treated with a median-chain triglycerides diet for 6weeks, three patients had transient phrenic nerve palsy with full recovery <6weeks, and one patient had a discrete
Horner syndrome that resolved in 6 weeks). The median time of follow-up was
19.50months (interquartile range, 14.00months). Postoperatively, there was a sig-
nicant decrease in the DASH score. Patients with rst rib remnants showed a signicant better response compared with patients without rst rib remnants.
2.2.2.4 ATOS: Outcome
ATOS is the least common presentation of TOS, accounting for 1% to 2% of cases.
Pantoja etal. [22] saw only 51 cases with ATOS among 2200 patients with TOS
between January 1986 and March 2021. Subclavian artery pathology included 16
aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Transaxillary
decompression was performed in 50 patients, including 50 rst rib resections and 23
transaxillary cervical rib resections. Among the 51 decompression cases, approximately 41% (21 cases) required arterial reconstruction: 13 open surgical reconstructions (11 bypass grafts, 2 primary aneurysm repairs) and 8 stentgraft repairs.
Comparing two time periods (1986–2003 vs 2003–2021), thrombolysis (5 vs 10)
and stentgraft repairs (0 vs 8) increased, whereas open subclavian artery repair (11
vs 2) decreased. Return-to-work rates (74% vs 96%) and good-excellent Derkash
scores (81% vs 96%) were comparable. The study described the evolving role of
endovascular management of ATOS over the past two decades and documented the
expanded role of vascular surgeons in the endovascular management of ATOS at a
single institution. Compared with open repair, stent graft repair of the subclavian
artery may be associated with shorter operative times, less blood loss, but decreased
patency, without changes in long-term functional outcomes.
2.2.2.5 Transaxillary Access
Stilo etal. [23] reported a single surgeon’s technique and experience with rst rib
resection through transaxillary approach, video-assisted in recent years, in 103
patients with TOS (NTOS 58.2%, VTOS 31.1%, ATOS 7.76%). Thirteen (12.6%)
patients had cervical rib and sixteen cases (15.5%) had bilateral TOS.The technical
success rate was 100%. Three patients (2.9%) presented with hand ischemia and
needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial
injury was reported, and nerve injury rate was 1.8%. At 30-day re-intervention rate
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was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage.
Restrict pneumothorax was reported in 42 patients (40.8%) treated with pleural
drainage. At mean follow-up of 93± 9 months partial symptoms recurrence was
present in 6 patients (5.8%). The authors advocated the transaxillary approach with
resection of the rst rib as a safe standard procedure for TOS.
Experience with a modication of the transaxillary rst and cervical rib resection
technique was described by Moridzadeh etal. [24]. Instead of transecting the ribs en
bloc, this approach relied on dividing the junction at the rst and cervical ribs and
then removing the individual segments. The separated segments of the rst rib could
then be individually distracted, allowing for improved mobilization, retraction, dissection, and removal of the individual segments. All cases were performed with the
assistance of high-denition video endoscopy. 38 patients had undergone complete
transaxillary resection of 40 fully formed cervical ribs (10 class 3 and 30 class 4).
Of these 38 patients, 74% were women. The presentations had been neurogenic
(65%), arterial (31%), and venous (5%). The duration of surgery averaged 141min,
blood loss was 65mL, and length of stay was 2.1 days. None of the patients had
experienced brachial plexus, phrenic, or long thoracic nerve injury. The average
follow-up period was 65months. The nal mean postoperative SPS and QuickDASH
scores were lower than the scores at presentation (SPS score, 6.4 vs 1.2; P<.001;
QuickDASH score, 50 vs 17; P< .001). Transaxillary resection of fully formed
cervical ribs should be considered a safe and effective operation.
2.2.2.6 Robotic Surgery
Martinez etal. [25] presented a retrospective review and analysis of data collected
from a 16-year experience of a single surgeon using a robotic surgical system and
technique for TOS surgery. 412 transaxillary decompression procedures using the
robotic da Vinci Surgical System were performed in 306 patients for rst rib resection and cervical band removal. In 204 (49%) procedures, the transaxillary approach
was used alone, and in 174 (41%) operations an open supraclavicular approach
preceded the robotic transaxillary approach (for cervical rib excision (n=48) and
anterior scalenectomy). In 126 of 412 (31%) operations, the supraclavicular
approach was for total anterior scalenectomy in patients who had predominantly
had cervical C5, C6, and C7 upper plexus syndrome. None of the patients died, and
no patient experienced permanent neurovascular damage of the extremity. Of the
306 patients, 22 (5% of 441 operations) experienced complications. One patient
developed postoperative scarring that required a redo operation with a roboticassisted transaxillary approach. The authors concluded that the endoscopic roboticassisted transaxillary approach offers a safe and effective approach for performing
thoracic outlet syndrome surgery because it provides a three-dimensional visual
magnication of the anatomic area and facilitates observation of the cervical bands
and the mechanism of neurovascular compression causing TOS.
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2.2.2.7 Botulinum Toxin Injections inPatients withNTOS
In a retrospective analysis, Donahue etal. [26] examined the role of botulinum toxin
(BTX) injections of anterior scalene (AS) and pectoralis minor (PM) muscles in
patients undergoing surgery for NTOS. They hypothesized that symptomatic
improvement from BTX injections correlates with favorable long-term response to
surgery for NTOS.Data of NTOS patients who underwent sonographically guided
chemodenervation of AS and PM using BTX type A followed by scalenectomy and
rst rib resection were analysed. A supraclavicular approach was chosen for the
surgical procedure. There were 157 patients with 178 BTX injections. A high proportion of responders to BTX injections also responded to surgery (positive predictive value of 99%), and BTX injections showed high specicity (90%). BTX
injections were moderately sensitive (66%) and accurate (67%) to determine surgical response and had low negative predictive value (14%). The study demonstrated
that favorable response to sonographically guided BTX injections is associated with
favorable surgical outcomes at 2years follow-up and has high positive predictive
value. While the positive predictive value of BTX injection was high, the negative
predictive value was low. Only 14% of patients who did not respond to BTX injection also did not respond to surgery. The low negative predictive value obviously
limits the value of the test.
2 Thoracic-Outlet-Syndrome
2.3 Conclusions forClinical Practice
1. Very few (randomised) studies are available on the treatment of TOS, evidence-
based statements on therapy cannot be made. The Society for Vascular Surgery
has adopted reporting standards. The standards dene terminology, local ndings, diagnostics, and severity assessment and describe the treatment and the
requirements for the presentation of results.
2. The therapy must be based on the ndings, whereby a strict distinction must be
made between neurogenic (NTOS), venous (VTOS), arterial (ATOS) TOS, and
their combinations.
3. In the major registries, rst rib resection is favoured as therapy, which is proba-
bly also justied if a cervical rib is in addition resected.
4. In NTOS, rst rib resection is controversial; supraclavicular decompression
without resection of the rst rib probably has the highest success rate in NTOS.In
VTOS (Paget-Schrötter syndrome), the data suggest that rst rib resection after
thrombolysis is the treatment of choice in the majority of patients.
5. It is undisputed that the care of TOS patients should be reserved for specialised
centres.
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