Arterial thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is used to describe the constellation of symptoms arising from neurovascular compression of the thoracic outlet. The structures passing through the thoracic outlet include the subclavian artery, subclavian vein and trunks of the brachial plexus. Patients may experience symptoms related to compression of any one or various combinations of these structures. Arterial pathology as the cause of TOS is rare, though repetitive overhead arm motion, such as seen in athletes, is a risk factor for developing arterial TOS (aTOS). Symptoms include chronic findings, such as pallor, arm claudication or cool arm. Currently diagnosis of aTOS is made using clinical and imaging parameters which include focused history and physical including provocative maneuvers and imaging follow-up ranging from angiography to MRI. Occasionally, acute thrombosis can result in limb threatening ischemia requiring emergent catheter directed thrombolysis. Outside of acute limb ischemia, management of aTOS is variable, however typically begins with conservative measures such as physical therapy. In patients who do not respond or progress on conservative management, surgical decompression may be performed. Open or endovascular treatment of subclavian artery pathology may be necessary for recalcitrant cases. In this article, the aim is to review the elements involving diagnosis and management of aTOS.