Summary: A 25-year-old woman presents with sudden onset of right hand numbness, discoloration and decrease
of pulse. Chest radiograph and computed tomography (CT) angiogram were obtained.
Thoracic outlet syndrome
demonstrates right larger than left anomalous cervical ribs. CT angiogram
performed with the patient’s arm in extreme abduction confirms narrowing of the
subclavian artery between the right cervical rib and clavicle. Additionally, thrombus
is seen within the distal brachial artery.
Thoracic outlet syndrome results from compression
of the neural, arterial, or venous structures crossing the interscalene
triangle, costoclavicular space, or retropectoralis minor space. Compression
may be secondary to posttraumatic deformities, anomalous cervical ribs, malignancy,
or normal anatomic structures such as the first rib, anterior scalene muscle,
and subclavius tendon.1 More than 90% of cases are neurogenic with only
a small minority of cases involving compression of the subclavian artery.1
Pain, paresthesias, and/or numbness are the
hallmark of brachial plexus compression. Swelling and pain may indicate venous
compression with subsequent subclavian vein thrombosis (Paget-Schroetter
syndrome). Chronic compression of the subclavian artery may lead to stenosis,
poststenotic dilatation, or aneurysm and compromised perfusion.2 In
cases of distal thromboembolism resulting from arterial compression, patients
present acutely with coolness, pallor, claudication, and/or diminished pulses.
Work-up for suspected thoracic outlet syndrome
begins with radiographs of the cervical spine and chest to rule out obvious
structural abnormalities. Postural maneuvers enhance the sensitivity of
angiography and cross-sectional imaging; scanning in a neutral position may
fail to reveal the exact site of compression.1
Acute limb ischemia warrants immediate revascularization with either catheter
directed thrombolysis or primary operation. Surgical decompression of the
thoracic outlet is generally recommended for cases of arterial involvement in
which a structural lesion can be identified.2,3 Stenting has little
role in primary intervention4 and is reserved for treatment of aneurysms
only after surgical decompression. Cases of severe fixed stenosis may require
surgical bypass or arterial reconstruction.
- Demondion X, Pascal H, van Sint Jan S et al. Imaging assessment of thoracic outlet syndrome.
- Dorazio RA, Ezzel F. Arterial complications of the thoracic
outlet syndrome. Am J Surg. 1979;138:246-250.
- Degeorges R, Reynaud C, Becquemin JP. Thoracic outlet syndrome surgery: Long-term functional
results. Ann Vasc Surg. 2004;18:558-565.
- Kieffer E, Ruotolo C. Arterial complications of thoracic outlet compression. In: Rutherford RB, ed. Vascular
surgery. 4th ed. Philadelphia, Pa: Saunders, 1995;992–997.