Can Vascular Flow Change During Provocation Maneuvers Predict Surgical Failure in Neurogenic Thoracic Outlet...

The need for simultaneous first rib resection during supraclavicular scalenectomy in patients with neurogenic thoracic outlet syndrome (NTOS) remains controversial. We have routinely evaluated vascular flow changes during provocation maneuvers through digital photoplethysmography. We asked whether the vascular flow change during provocation maneuvers can predict surgical failure after isolated supraclavicular scalenectomy for NTOS.

For 50 patients (mean age of 42.0 ± 16.5 years) who underwent supraclavicular scalenectomy for NTOS, we evaluated vascular flow change through digital photoplethysmography during several provocation maneuvers including Roos test, costoclavicular maneuver, and Adson maneuver before surgery. We calculated the adjusted odds ratio (OR) for surgical failure in association with the vascular flow change during each maneuvers with age, symptom duration, electrodiagnostic study findings, and the number of visible vertebrae as covariates.

Compared to the resting position, mean vascular flow during Roos test, costoclavicular maneuver, and Adson maneuver was 46.0 ± 51.3%, 42.9 ± 48.2%, and 85.4 ± 64.1%, respectively. Twelve patients (24%) were classified into surgical failure, and symptom duration (adjusted OR = 1.04, P = 0.04) and absent vascular flow during costoclavicular maneuver (adjusted OR = 23.30, P = 0.01) were significantly associated with failure.

A quantitative evaluation of the vascular flow changes that occur during provocation maneuvers can aid not only the diagnosis of NTOS but also help determine the optimal surgical treatment. In particular, if patients show absent blood flow during the costoclavicular maneuver, simultaneous scalenectomy and first rib resection should be considered.