Thoracic outlet syndrome: Treatment approaches

Purpose of review: Thoracic Outlet Syndrome (TOS) is a spectrum of neurovascular compression affecting the upper extremity. Recent findings: The structures in the thoracic outlet involved in this compression are the brachial plexus, the subclavian artery, and the subclavian vein. Each of these structures has its own symptom complex. Neurogenic TOS is best treated with physical therapy, with subsequent surgical decompression if there are continued symptoms. Women were reported to have neurogenic TOS more frequently than men in several large series but tend to have a good response to decompression. Venous TOS is an acute-on-chronic process, where chronic injury to the subclavian vein results in acute thrombosis. Treatment involves a staged approach of thrombolysis followed by surgical decompression, allowing for a high rate of success and removing the need for long-term anticoagulation. Arterial TOS is defined by pathologic injury to the subclavian artery due to underlying bony anomalies such as cervical rib or anomalous first rib, which results in distal thrombo-emboli and potential limb-threatening ischemia. Treatment involves surgical decompression with varying types of revascularization depending on the patient presentation. Summary: Decompression of the thoracic outlet is central to the management of all forms of TOS. Women tended to make up a larger percent of the neurogenic case series, with equivalent functional outcomes to men. There was no consistent difference in rates for arterial TOS based on sex, with variable rates of reported prevalence in venous TOS, and the treatment algorithms for both are the same.