Management of Arterial Thoracic Outlet Syndrome

Diagnostic Confirmation and Surgical Management

All patients with arterial TOS require surgical thoracic outlet decompression with first rib resection and anterior scalenectomy, and most (approximately 69%) will also need subclavian artery reconstruction, as recommended by the American College of Surgeons 1
Obtain chest radiography first to identify cervical ribs, first rib anomalies, or other bony abnormalities causing the compression, as suggested by the American College of Radiology 1, 2
Perform CTA with IV contrast in both neutral and elevated arm positions to assess arterial compression, stenosis, or occlusion, and use sagittal reformations, not just axial slices, as axial views underestimate stenosis in 43% of cases versus only 10% with sagittal views, according to the Journal of the American College of Radiology 1, 2, 3
Subclavian artery reconstruction is warranted when imaging or intraoperative findings reveal intimal damage to the artery, mural thrombus, aneurysmal dilation, or significant stenosis or occlusion, as recommended by the Society for Vascular Surgery 1, 2

Expected outcomes after appropriate surgical management include subclavian artery/graft primary patency of 87% at 5 years and secondary patency of 90% at 5 years, with most patients (82% in one series) returning to work, as reported by the American College of Surgeons 1