Vascular: Venous Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS)

Definition

Anatomy

Types

Neurogenic Thoracic Outlet Syndrome
- Compression of the Brachial Plexus
- Most Common Type (95%)
- *See Cardiothoracic Surgery: Neurogenic Thoracic Outlet Syndrome
Venous Thoracic Outlet Syndrome (Paget-von Schroetter Syndrome)
- Compression of the Subclavian Vein
- Accounts for 3% of TOS
Arterial Thoracic Outlet Syndrome
- Compression of the Subclavian Artery
- Least Common Type (1%)
- Strongest Indication for Surgical Intervention
- *See Vascular: Arterial Thoracic Outlet Syndrome

Basics

Also Known As:
- Paget-von Schroetter Syndrome
- Effort-Induced Thrombosis
Cause: Compression of the Subclavian Vein
Etiology: Repetitive Overhead Shoulder Movements or Coagulopathy
- Anterior Scalene Hypertrophy Causes Compression
- Induces Venous Stenosis with/without Thrombosis
Most Common in Pitchers & Swimmers

Presentation

Arm Swelling
Arm Cyanosis
Arm Pain
Complications:
- Pulmonary Embolism
- Upper Extremity Phlegmasia Cerulea Dolens (Venous Gangrene)

Diagnosis

Diagnosis: Duplex Ultrasound
- If Negative but High Degree of Suspicion: Venography (Gold Standard)

Treatment

Primary Treatment: Catheter Directed Thrombolysis Therapeutic Anticoagulation (Heparin)
Surgical Decompression:
- Indications:
  - Persistent Stenosis After Thrombolysis
  - Signs of Extrinsic Compression After Thrombolysis
- Surgery: First Rib Resection & Anterior Scalene Division
  - Treatment of Vein Stenosis After Rib Resection:
    - Angioplasty with/without Stenting
    - Surgical Thrombectomy, Patching or Bypass
- Timing: During Same Admission (Decreased Risk of Re-Occlusion)
Balloon Angioplasty & Stenting Alone Do Not Provide Sufficient Durability for Definitive Treatment

Subtle Arm Swelling Due to Subclavian Vein Thrombosis ¹

Duplex US Showing Subclavian Vein Thrombosis ²

Venogram Showing Subclavian Vein Thrombosis ³

Kidd M, Broderick V. An unusual presentation of a swollen arm: a case report. J Med Case Rep. 2014 Jan 27;8:22. (License: CC BY-2.0)
Ilhan E, Ture M, Yilmaz C, Arslan M. Subclavian Vein Thrombosis Extending into the Internal Jugular Vein: Paget-von Schroetter Syndrome. J Clin Med Res. 2009 Aug;1(3):178-80. (License: CC BY-2.0)
Ijaopo R, Oguntolu V, DCosta D, Garnham A, Hobbs S. A case of Paget-Schroetter syndrome (PSS) in a young judo tutor: a case report. J Med Case Rep. 2016 Mar 18;10:63.(License: CC BY-4.0)