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Síndrome de Compressão Torácica
Síndrome de Compressão Torácica
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Vascular Medicine
Keywords
Thoracic Outlet Syndrome, paget schroetter, brachial plexus compression, upper extremity deep vein thrombosis,
subclavian artery aneurysm
Figure 1. Diagram of the anatomy of the thoracic outlet showing the subclavian artery, vein, and brachial plexus (nerve bundle)
passing through the anterior scalene muscle, which attaches to the first rib. (Illustration printed with permission. © Amy Zhong.)
different types of TOS. Some symptoms can overlap, and For venous or arterial TOS, common tests used for
patients can occasionally have more than one type, so fur- diagnosis include CT or Doppler ultrasound studies.
ther evaluation with a careful physical examination and Occasionally, a venogram may be performed to diagnose
ultrasound tests may be necessary. and treat TOS. A venogram is a procedure in which a small
tube is inserted into the vein, and dye is injected into it to
show the veins under real-time X-ray imaging. Thrombolysis
How is thoracic outlet syndrome may be needed, which is a procedure that dissolves blood
diagnosed? clots. Angiography (which is similar to venography except
Thoracic outlet syndrome is diagnosed through a combina- that the dye is used to see the arteries instead of the veins)
tion of patient history, physical examination findings, and may be useful in arterial TOS.
imaging studies. Since TOS is rare, the diagnosis can be eas-
ily missed, and it is common for patients to have seen mul- How is thoracic outlet syndrome
tiple specialists without a clear diagnosis or understanding
of the cause of their symptoms. A physical therapist or even
treated?
the patient might be the first to suspect the diagnosis. The treatment depends on the type of TOS. Neurogenic
Depending on the type of TOS that is suspected, patients TOS is often initially treated with thoracic outlet-specific
are evaluated with a variety of physical examination tests physical therapy. Many patients are able to get relief with-
that help to confirm the diagnosis. Common tests for neuro- out the need for surgical intervention. If symptoms do not
genic TOS include the Adson’s maneuver, the elevated arm improve with physical therapy alone, in some cases botuli-
stress test (EAST), and the upper extremity tension test (also num toxin A (BOTOX®) injections into the anterior and
known as Elvey’s test). In the Adson’s maneuver, the radial middle scalene muscles can be tried in conjunction with
pulse at the wrist is felt while the arm is raised away from the physical therapy. Surgical decompression procedures are
body. This test alone does not confirm a diagnosis of TOS, an option if less invasive treatments are not successful.
since some people with no symptoms can have a decrease or The treatment of venous TOS depends on how long the
disappearance of the pulse at the wrist with moving the arm condition has been present. Patients who have the sudden
away from the body. The elevated arm stress test (EAST) is onset of venous TOS and have arm DVT are frequently
also performed with the arms elevated to provoke symptoms. treated first with thrombolysis (clot-busting medications)
The upper extremity tension test (Elvey’s test) checks for to dissolve the thrombosis, along with blood-thinning
pinching of the nerve at the thoracic outlet. Peripheral nerves medications. Treatment is then continued with a surgical
are tested along with range of motion in the arm. decompression procedure to relieve the compression on
Frequently, patients with TOS symptoms may have had the vein that caused the arm DVT to form. Blood flow in
many diagnostic tests including magnetic resonance imag- the vein frequently can be improved by inflating a small
ing (MRI) studies, computed tomography (CT or CAT) balloon inside the vein and inserting a stent to prop the
scans, nerve conduction studies (NCS), electromyography vein open. Open surgical venous reconstruction is rarely
(EMG), or ultrasounds. Imaging can help with the diagno- necessary.
sis of venous or arterial TOS, but patients with neurogenic Patients with arterial TOS often require surgical decom-
TOS may have normal tests. Nevertheless, these tests may pression procedures to remove the rib and/or scalene mus-
be necessary to look for other more common diagnoses. cles, including reconstruction procedures for the damaged
artery, which may be aneurysmal (dilated) or contain a on the type of TOS (neurogenic, venous, or arterial) and
blood clot. should be tailored to best address the patient’s symptoms
Physical therapy remains an integral part of recovery and expectations.
after any surgical intervention. Patients may also have to
remain on blood thinners for a period of time after surgery. Declaration of conflicting interest
The authors declare that there is no conflict of interest.
Conclusion Funding
Thoracic outlet syndrome is a rare disorder that can be chal- This research received no specific grant from any funding agency
lenging to diagnose accurately. The treatment plan depends in the public, commercial, or not-for-profit sectors.