From the Midwestern Vascular Surgical Society

Clinical presentation and management of arterial thoracic

outlet syndrome
Chandu Vemuri, MD, Lauren N. McLaughlin, ACNP, Ahmmad A. Abuirqeba, BA, and
Robert W. Thompson, MD, St. Louis, Mo

ABSTRACT
Objective: Arterial thoracic outlet syndrome (TOS) is a rare condition characterized by subclavian artery pathology
associated with a bony abnormality. This study assessed contemporary clinical management of arterial TOS at a high-
volume referral center.
Methods: A prospectively maintained database was used to conduct a retrospective review of patients undergoing
primary or reoperative treatment for arterial TOS during an 8-year period (2008 to 2016). Presenting characteristics,
operative findings, and clinical and functional outcomes were evaluated.
Results: Forty patients underwent surgical treatment for arterial TOS, representing 3% of 1401 patients undergoing oper-
ations for all forms of TOS during the same interval. Patients were a mean age of 40.3 6 2.2 years (range, 13-68 years), and
72% were women. More than half presented with upper extremity ischemia/emboli (n ¼ 21) or posterior stroke (n ¼ 2),
including eight that had required urgent brachial artery thromboembolectomy. The presentation in 17 (42%) was
nonvascular, with 11 having symptoms of neurogenic TOS and six having an asymptomatic neck mass or incidentally
discovered subclavian artery dilatation. All patients underwent thoracic outlet decompression (25 supraclavicular, 15 para-
clavicular), of which there were 30 (75%) with a cervical rib (24 complete, 6 partial), 5 with a first rib abnormality, 4 with a
clavicle fracture, and 1 (reoperation) with no remaining bone abnormality. Subclavian artery reconstruction was performed
in 70% (26 bypass grafts, 1 patch, 1 suture repair), and 30% had mild subclavian artery dilatation (<100%) requiring no arterial
reconstruction. Mean postoperative length of stay was 5.4 6 0.6 days. During a mean follow-up of 4.5 6 0.4 years (range, 0.9-
8.1 years), subclavian artery patency was 92%, none had further dilatation or embolism, and chronic symptoms were present
in six (4 postischemic/vasospasm, 2 neurogenic). Functional outcomes measured by scores on the 11-item version of the
Disability of the Arm, Shoulder and Hand Outcome Measure improved from 39.1 6 3.8 to 19.2 6 2.7 (P < .0001).
Conclusions: This relatively large single-institution series demonstrates the diverse clinical presentation of arterial TOS
coincident with a spectrum of bony and arterial pathology. Current surgical protocols can achieve excellent outcomes for
this rare and often complicated condition. (J Vasc Surg 2017;65:1429-39.)

One hundred years ago, Dr William Halsted presented
the first large collected clinical series of patients with
subclavian artery aneurysms in association with cervical
rib anomalies.1 He and others subsequently investigated
From the Center for Thoracic Outlet Syndrome and the Section of Vascular
Surgery, Department of Surgery, Washington University in St. Louis School
of Medicine.
This work was partly supported by the Thoracic Outlet Syndrome Research and
Education Fund of the Barnes-Jewish Hospital Foundation, St. Louis, Mo.
Author conflict of interest: none.
Presented at the Fortieth Annual Meeting of the Midwestern Vascular Surgical
Society, Columbus, Ohio, September 8-10, 2016.
Correspondence: Robert W. Thompson, MD, Center for Thoracic Outlet Syn-
drome, Section of Vascular Surgery, Washington University in St. Louis School
of Medicine, 5101 Queeny Tower, One Barnes-Jewish Hospital Plaza, Campus
Box 8109, St. Louis, MO 63110 (e-mail: thompson@wudosis.wustl.edu).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2016 The Authors. Published by Elsevier Inc. on behalf of the So-
ciety for Vascular Surgery. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.jvs.2016.11.039
the unique pathophysiologic implications of this re-
lationship and defined poststenotic dilatation as a
distinct mechanism of aneurysm formation.2-4 Subcla-
vian artery aneurysms and other pathologic lesions are
now recognized as part of the spectrum of conditions
known as thoracic outlet syndrome (TOS), which in-
cludes brachial plexus compression (neurogenic TOS)
and subclavian vein effort thrombosis (venous TOS).5
Arterial TOS is the least frequent form of these condi-
tions, but its clinical presentation is distinguished by
the potential for life- and limb-threatening thromboem-
bolic complications.6-16
In 2008 we established a multidisciplinary center
approach to focus on TOS to standardize and optimize
protocols for the evaluation and treatment of all forms
of TOS. The purpose of this study was to assess the pre-
senting characteristics and contemporary management
of arterial TOS at a single high-volume referral center.17,18
METHODS
All patients in this study gave informed consent for the
publication of their medical data through a protocol

1429
1430 Vemuri et al
approved by the Human Research Protection Office at
Washington University in St. Louis, St. Louis, Mo.
Patient population, inclusion and exclusion criteria.
Patients treated for arterial TOS were identified using a
prospectively maintained database of all patients treated
at the Washington University in St. Louis Center for
Thoracic Outlet Syndrome at Barnes-Jewish Hospital, St.
Louis, Mo, from January 2008 through December 2016.
Arterial TOS was defined as the existence of subclavian
artery pathology (aneurysmal dilatation, occlusion, steno-
sis, or embolizing ulceration) in the presence of a
congenital or acquired bony abnormality within the
thoracic outlet. These bony abnormalities included
congenital cervical rib or hypoplastic first rib anomalies
and acquired fractures of the clavicle or first rib, as evident
on plain radiographic studies before the operation.
The study excluded patients with subclavian artery
pathology not associated with a bony abnormality and
patients with compressive arterial lesions confined to
the axillary artery or its branches. Patients presenting
with symptoms of neurogenic TOS associated with a
bony abnormality who were subsequently found to
have coincident subclavian artery pathology were
included, as were patients with incidentally identified
asymptomatic subclavian artery lesions in the presence
of a previously unrecognized bony abnormality. Patients
with a clinical examination demonstrating neurogenic
TOS and only positional compression of the subclavian
artery were excluded, as were patients with neurogenic
TOS accompanied by peripheral (hand or finger) vaso-
constriction caused by sympathetic overactivity but
with no subclavian artery pathology.
Clinical management protocol. Patients presenting
with acute upper extremity ischemia were treated with
urgent brachial artery thromboembolectomy, with or
without adjunctive thrombolytic therapy, at our medical
center or at the hospital of origin, followed by maintenance
anticoagulation and evaluation for subclavian artery pa-
thology and arterial TOS. Those found to have arterial
TOS underwent surgical treatment, typically within several
days to weeks of their initial presentation. Asymptomatic
individuals and patients presenting with neurogenic TOS
who were found to have bony abnormalities and overt sub-
clavian artery lesions underwent elective surgical treat-
ment for arterial TOS. Radiographic assessment for bony
abnormalities included anterior-posterior chest x-ray im-
aging and computed tomography (CT) scans. Assessment
of the subclavian artery was performed using contrast-
enhanced magnetic resonance angiography (MRA), CT
angiography (CTA) with three-dimensional image recon-
struction, or direct catheter-based arteriography.19
Surgical treatment. Surgical treatment for arterial TOS
consisted of supraclavicular thoracic outlet decompression
Journal of Vascular Surgery
May 2017
ARTICLE HIGHLIGHTS
d
Type of Research: Single center retrospective cohort
study
d
Take Home Message: In 40 patients with arterial
thoracic outlet syndrome, excellent results, including
a 92% subclavian artery/graft patency at 4.5 years,
and equally excellent functional outcome could be
achieved.
d
Recommendation: This study suggests a distinct
surgical protocol to achieve excellent outcomes for
patients with arterial thoracic outlet syndrome.
with complete anterior and middle scalenectomy, brachial
plexus neurolysis, and resection of the cervical rib and first
rib.20 Direct surgical repair of the subclavian artery was
performed in the same operation for subclavian artery
aneurysms with a diameter 100% greater than the unaf-
fected proximal subclavian artery, embolizing lesions, or for
thrombotic occlusion, but repair was not performed for
poststenotic subclavian artery dilatation <100%.
When distal control of the subclavian artery could not
be obtained from the supraclavicular incision alone, a
lateral infraclavicular incision was added for exposure
and control of the axillary artery.21 For arterial repair,
the distal anastomosis was performed first, followed
by the proximal anastomosis, by using end-to-end inter-
position grafting technique. The preferred conduits for
repair included cryopreserved femoral artery, cryopre-
served femoral vein, or woven Dacron (DuPont, Wil-
mington, Del).
Outcomes measures. Hospital length of stay and post-
operative complications were recorded. Clinical assess-
ment of the results for arterial reconstruction included
examination for any evidence of digital emboli or is-
chemia, bilateral upper extremity blood pressures, and
pulse waveforms on noninvasive vascular laboratory
testing or imaging studies (MRA, CTA, or catheter-
based arteriography), when indicated. Outcomes were
also assessed using several patient-reported survey in-
struments previously used in the assessment of patients
with TOS, including the 11-item version of the Disability
of the Arm, Shoulder and Hand (QuickDASH) Outcome
Measure (scale 0-100), the Cervical-Brachial Symptom
Questionnaire (CBSQ; scale 0-100), and the McGill Pain
Questionnaire, which includes a 10-point visual analog
scale for pain, the Pain Rating Index, and the Overall
Pain Intensity instruments, and is assessed on a 0-100
scale.22
Statistical analysis. Descriptive data are reported as
the group percentage or the mean 6 standard error of
the mean. Patient-reported outcomes measures were
Journal of Vascular Surgery
Volume 65, Number 5
Fig 1. Flow diagram describes the presenting characteristics, bony abnormalities, and arterial abnormalities in
40 patients treated for arterial thoracic outlet syndrome (TOS). Rxn, Resection.
compared using two-tailed, unpaired t-tests with the
Welch correction. Analyses were conducted using Prism
6.0 software (GraphPad Software, Inc, La Jolla, Calif). For all
tests, a P value of <.05 was considered to be statistically
significant.
RESULTS
Clinical presentation. Forty patients underwent surgi-
cal treatment for arterial TOS from 2008 to 2016, repre-
senting 3% of 1401 patients treated for all forms of TOS
during the same interval (Fig 1). Patients were a mean
age of 40.3 6 2.2 years (range, 13-68 years), and 72% were
women (Table I). Vascular complications were present in
23 patients (58%), either upper extremity ischemia/
emboli (n ¼ 21) or posterior stroke (n ¼ 2), including eight
who had recently required urgent brachial artery
thromboembolectomy (3 with adjunctive use of throm-
bolytic therapy; Fig 2). The presentation was nonvascular
in 17 patients (42%), including 11 with primary symptoms
of neurogenic TOS and six with an asymptomatic neck
Vemuri et al 1431
mass or incidentally discovered subclavian artery dilata-
tion, which had led to the recognition of subclavian ar-
tery pathology in association with a bony abnormality. A
cervical rib was identified by preoperative radiographic
studies in 30 patients (75%), with no difference between
patients with a vascular (74%) or nonvascular (76%) pre-
sentation (Fig 3).
Surgical treatment. All patients underwent thoracic
outlet decompression. A supraclavicular approach alone
was used in 25 (65%), and a combined supraclavicular
and infraclavicular (paraclavicular) approach was used
in 15 (35%; Table II). There were 30 patients (75%) with a
cervical rib (24 complete, 6 partial), 5 with a first rib
abnormality, 4 with a clavicle fracture, and 1 with no bony
abnormality (a reoperative procedure in which the cer-
vical and first ribs had been previously removed). Nine-
teen patients (48%) had a large post-stenotic subclavian
artery aneurysm, 7 (17%) had thrombosis of the subcla-
vian artery, and 11 (28%) had poststenotic subclavian
1432 Vemuri et al Journal of Vascular Surgery
May 2017

Table I. Presenting characteristics in patients with arterial subsequent balloon angioplasty for an anastomotic ste-
thoracic outlet syndrome (TOS) nosis identified on follow-up arteriography, and two
Vascular Nonvascular Total other patients underwent operative revision for an
Characteristica (n ¼ 23) (n ¼ 17) (N ¼ 40) occluded bypass graft (Table IV). At the end of follow-
Age, years 40.3 6 2.4 40.2 6 4.0 40.3 6 2.2 up, the subclavian artery was patent in 38 patients
Female gender, % 15 (65) 14 (82) 29 (72) (92%), with three having had bypass graft occlusion
Right side affected, % 10 (44) 12 (71) 22 (55) (Table IV). These three individuals had a complicated
Dominant side affected 12 (52) 10 (59) 22 (55)
vascular presentation upon referral: one with previous
brachial artery thromboembolism and treatment with
Ischemia/emboli 21 (91) 0 (0) 21 (52)
multiple subclavian artery stents, one with recent
Posterior stroke 2 (9) 0 (0) 2 (5)
brachial artery thromboembolectomy and occlusion of
Neurogenic TOS 0 (0) 11 (65) 11 (28)
a previous subclavian artery bypass graft, and one with
Asymptomatic neck mass 0 (0) 6 (35) 6 (15) several years of arm symptoms caused by chronic throm-
Recurrent arterial TOS 1 (4) 2 (12) 3 (7) boembolism and a recent posterior stroke. Each of these
Recent thrombectomy 8 (35) 0 (0) 8 (20) patients underwent thoracic outlet decompression with
Cervical rib 17 (74) 13 (76) 30 (75) a subclavian artery bypass, of which two eventually
a
Continuous data are shown as the mean 6 standard error of the mean required further reoperations for bypass graft occlusion
and categoric data as number (%) or as indicated. (one successful, one with later rethrombosis). No other
patients had bypass graft stenosis or occlusion, further
subclavian artery dilatation, or thromboembolism.
artery dilatation that did not meet the threshold for
Chronic symptoms were present in six patients (15%),
reconstruction (maximal extent of dilatation was <100%
four with longstanding postischemic symptoms in the
of the normal proximal artery).
hand despite revascularization and two with symptoms
As reported in Table III, operative treatment included
of neurogenic TOS.
complete anterior and middle scalenectomy in all pa-
tients and bone resection in 36 (90%), including com- Functional outcome measures. Patients presenting
bined resection of a cervical rib and first rib in 29 (72%), with arterial TOS exhibited a high level of disability by
resection of a first rib alone in 6 (15%), and resection of functional outcome measures, as reflected by scores
a cervical rib alone in 1 (2%). Direct subclavian artery on the QuickDASH, CBSQ, and McGill Pain Question-
reconstruction was performed in 28 patients (70%), naire (Table V; Fig 5). By these measures, patients
with resection and interposition bypass grafting in 26 presenting with vascular complications also had a
(65%) using cryopreserved femoral artery in 12 (30%), cry- consistently higher level of disability than patients with
opreserved femoral vein in 10 (25%), and woven Dacron in a nonvascular presentation (QuickDASH score: 47.6 6
4 (10%; Fig 4). Endarterectomy for an ulcerated subcla- 4.9 vs 27.3 6 4.8, P ¼ .0056; CBSQ score: 53.8 6 7.6 vs
vian artery plaque was performed in one patient, and 32.1 6 5.9, P ¼ .0316).
suture repair for a pseudoaneurysm was performed Functional outcomes measures were markedly
in another. Seven patients (17%) underwent concomitant improved during postoperative follow-up for the overall
axillary or brachial artery thromboembolectomy at group and also for patients with vascular and non-
the time of subclavian artery reconstruction, but no vascular presentations (Table V; Fig 5). Thus, QuickDASH
thrombolytic agents were administered intraoperatively scores for the entire group were 44% 6 12% lower at
because of the risk of bleeding (Table IV). Twelve patients follow-up than before surgical treatment, and CBSQ
(30%) had no subclavian artery reconstruction, undergo- scores were 59% 6 9% lower. McGill Pain scores were
ing observation alone for a mild extent (<100%) of post- more variable and not affected as substantially, with
stenotic dilatation. scores at follow-up 38% 6 17% lower than before surgical
treatment for the entire group, but there were no differ-
Clinical follow-up. Mean postoperative length of stay was
ences for this measure between the vascular and nonvas-
5.4 6 0.6 days, with no difference between patients with a
cular subgroups.
vascular (5.3 6 0.6 days) or a nonvascular (5.4 6 1.2 days)
presentation. One patient (2%) died of sepsis from an unre-
lated condition #30 days of surgical treatment. One patient DISCUSSION
was readmitted #2 weeks of surgery for nausea and insuffi- In this study we used a relatively strict definition of arte-
cient postoperative pain control, but there were no other rial TOS, with inclusion criteria requiring the presence of
early postoperative complications. a bony abnormality within the thoracic outlet and overt
During a mean follow-up of 4.5 6 0.4 years (median, pathology of the subclavian artery.5 In the past, broader
4.3 years; range, 0.9-8.1 years), there were no deaths or definitions of arterial TOS have often included patients
amputations. Two of the 26 patients who underwent with neurogenic upper extremity symptoms (pain,
subclavian artery bypass graft reconstruction required numbness, and paresthesia) along with positional
Journal of Vascular Surgery Vemuri et al 1433
Volume 65, Number 5

Fig 2. A 28-year-old right-handed man presented with right hand digital ischemia caused by a subclavian
artery aneurysm. A, A right upper extremity arteriogram demonstrated a subclavian artery aneurysm, throm-
boembolic occlusion of the distal brachial artery, and multiple embolic digital artery occlusions. Magnified
arteriographic views of the (B) affected right hand and (C) normal left hand illustrate the differences in
perfusion. D, Ischemic fingertip lesions in the right hand. E, Brachial artery thromboembolectomy and patch
angioplasty repair was initially performed. F, Operative specimens of the cervical and first ribs removed during
supraclavicular thoracic outlet decompression several days after thrombectomy. G, Subclavian artery aneurysm
(SCA) viewed from right supraclavicular exposure. H, The excised specimen of the subclavian artery aneurysm
demonstrated intimal ulceration with thrombus. I, Subclavian artery repair with interposition bypass graft.
(Reprinted with permission from Thompson RW. Management of digital emboli, vasospasm, and ischemia in
ATOS. In: Illig KA, Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI, editors. Thoracic Outlet
Syndrome. London: Springer; 2013: 557-63.)
1434 Vemuri et al Journal of Vascular Surgery
May 2017

Fig 3. Imaging of arterial thoracic outlet syndrome (TOS). A and B, Plain chest radiograph illustrates a right
cervical rib. C and D, Contrast-enhanced computed tomography (CT) scan with three-dimensional reconstruction
demonstrates a right cervical rib and a poststenotic subclavian artery aneurysm with no mural thrombus.

Table II. Operative findings in patients with arterial thoracic outlet syndrome (TOS)
Variable Vascular (n ¼ 23), No. (%) Nonvascular (n ¼ 17), No. (%) Total (N ¼ 40), No. (%)
Operative approach
Supraclavicular 11 (48) 14 (82) 25 (63)
Paraclavicular 12 (52) 3 (18) 15 (37)
Bone abnormalities
Cervical rib 17 (74) 13 (76) 30 (75)
Complete 14 (61) 10 (59) 24 (60)
Partial 3 (13) 3 (18) 6 (15)
First rib abnormality 3 (13) 2 (12) 5 (12)
Clavicle fracture 2 (9) 2 (12) 4 (10)
No bony abnormality 1 (4) 0 (0) 1 (3)
Subclavian artery abnormalities
Large aneurysm 12 (52) 7 (41) 19 (48)
Thrombosis 7 (24) 0 (0) 7 (18)
Dilatation <100% 2 (9) 9 (53) 11 (27)
Patent previous bypass 1 (4) 0 (0) 1 (3)
Pseudoaneurysm 0 (0) 1 (6) 1 (2)
Ulcerated plaque 1 (4) 0 (0) 1 (3)
Journal of Vascular Surgery Vemuri et al 1435
Volume 65, Number 5

Table III. Operative treatment in patients with arterial thoracic outlet syndrome (TOS)
Variablea Vascular (n ¼ 23) Nonvascular (n ¼ 17) Total (N ¼ 40)
Scalene muscle resection
Anterior scalene weight, grams 5.7 6 0.4 5.5 6 0.4 5.6 6 0.3
Middle scalene weight, grams 4.5 6 0.9 4.5 6 0.6 4.4 6 0.6
Bone resection
First rib and cervical rib 16 (70) 13 (76) 29 (73)
Cervical rib alone 1 (4) 0 (0) 1 (2)
First rib alone 4 (17) 2 (12) 6 (15)
No bone resection 2 (9) 2 (12) 4 (10)
Subclavian artery reconstruction
Resection and bypass graft 19 (83) 7 (41) 26 (66)
Cryopreserved artery 9 (39) 3 (18) 12 (30)
Cryopreserved vein 8 (35) 2 (12) 10 (25)
Dacronb 2 (9) 2 (12) 4 (10)
Endarterectomy alone 1 (4) 0 (0) 1 (2)
Suture repair alone 0 (0) 1 (6) 1 (2)
Observation alone 3 (13) 9 (53) 12 (30)
a
Continuous data are presented as the mean 6 standard error of the mean and categoric data as number (%).
b
DuPont, Wilmington, Del.

Fig 4. Subclavian artery reconstruction is shown in a 20-year-old woman with an asymptomatic right subcla-
vian artery aneurysm (all views from the right side with supraclavicular exposure). A, Subclavian artery (SCA)
aneurysm is demonstrated after scalenectomy and resection of the cervical and first ribs. After mobilization of
the distal artery into the supraclavicular exposure, clamps were placed and the aneurysmal segment was
excised in preparation for an interposition bypass using a cryopreserved femoral artery graft. B, Distal anasto-
mosis. C, Proximal anastomosis. D, Completed bypass graft. BP, Brachial plexus; Clav, clavicle.

compression of the subclavian artery on physical exami-
nation, vascular laboratory tests, or imaging studies.15
However, even in the presence of a bony abnormality,
symptoms in patients without subclavian artery pathol-
ogy are more readily attributable to brachial plexus
compression rather than to any significant degree of
arterial insufficiency caused by the transient subclavian
artery obstruction that occurs with positional compres-
sion. Management in such patients is more appropriately
directed toward neurogenic TOS than toward alleviating
positional subclavian artery compression. Some patients
with longstanding and severe neurogenic TOS also
exhibit intermittent digital paresthesia, discoloration,
and cold sensation in the absence of a bony abnormality,
1436 Vemuri et al Journal of Vascular Surgery
May 2017

Table IV. Subclavian artery reconstruction in patients with arterial thoracic outlet syndrome (TOS)
Distal thrombectomy at primary Later graft Patent bypass at
Subclavian artery bypass graft conduit No. operation, No. revision, No. follow-up, No. (%)
Cryopreserved femoral artery 12 4 2a 11 (92)
Cryopreserved femoral vein 10 3 1b 9 (90)
Woven Dacronc 4 2 1b 4 (100)
Total 26 9 4 24 (92)
a
Balloon angioplasty for anastomotic stenosis.
b
Operative revision for graft occlusion.
c
DuPont, Wilmington, Del.

Table V. Functional outcome measures in patients with arterial thoracic outlet syndrome (TOS)
Outcome measurea Vascular (n ¼ 23) Nonvascular (n ¼ 17) P valueb,c Total (N ¼ 40)
QuickDASH score
Preoperative 47.6 6 4.9 27.3 6 4.8 .0056 39.1 6 3.8
Postoperative 23.9 6 3.9 13.9 6 3.3 .0629 19.2 6 2.7
P valued .0006 .0297 <.0001
% Change 53 6 5 32 6 27 44 6 12
CBSQ score
Preoperative 53.8 6 7.6 32.1 6 5.9 .0316 44.3 6 5.3
Postoperative 23.5 6 5.4 12.6 6 3.6 .1059 18.4 6 3.4
P valued .0029 .0105 .0001
% Change 65 6 6 51 6 18 59 6 9
McGill Pain Score
Preoperative 15.3 6 3.1 10.1 6 2.5 .2042 13.1 6 2.1
Postoperative 8.1 6 2.2 5.6 6 1.1 .3163 7.0 6 1.3
P valued .0666 .1122 .0173
% Change 31 6 26 49 6 15 38 6 17
CBSQ, Cervical-Brachial Symptom Questionnaire; QuickDASH, 11-item version of the Disabilities of Arm, Shoulder and Hand Outcome Measure.
a
Data represent the mean 6 standard error of the mean.
b
Statistical comparisons were made by two-tailed, unpaired t-tests with the Welch correction.
c
Vascular vs nonvascular.
d
Preoperative vs postoperative.

thromboembolism, or overt subclavian artery pathology.
Clinical and imaging evaluations demonstrate that these
individuals most typically have sympathetic-mediated
vasospasm related to chronic brachial plexus nerve
compression rather than authentic arterial TOS.23,24
This study also excluded patients with distal axillary ar-
tery compression at the level of the humeral head, a con-
dition that we have described previously as almost
exclusively occurring in high-performance overhead ath-
letes.25 Axillary artery and branch vessel lesions in this
condition can produce thromboembolic complications
similar to those observed in arterial TOS, but this is a
separate disorder with different implications for surgical
treatment. Distinguishing between these various clinical
presentations remains an important aspect of evaluation
in patients with different forms of TOS and in interpret-
ing the results of clinical management.
The present study demonstrates excellent clinical out-
comes using standardized evaluation and protocol-driven
treatment strategies for arterial TOS, which is emphasized
in our multidisciplinary center approach to all forms of
TOS that integrates expertise in vascular surgery, physical
therapy, pain management, interventional radiology, and
other specialties.
Like others, we have found that patients with arterial
TOS can be readily separated into two patterns of clin-
ical presentation by the presence or absence of vascular
complications.6-17 Patients with a nonvascular presenta-
tion may be further divided into those with symptoms
attributable to neurogenic TOS and those who are
completely asymptomatic. Surgery may be indicated
in these patients for the treatment of neurogenic TOS
unresponsive to conservative management or for the
prevention of subclavian artery complications in those
with poststenotic dilatation. A high index of suspicion
for subclavian artery pathology should be applied to pa-
tients with a cervical rib or first rib anomaly, where
definitive imaging by contrast-enhanced CT, magnetic
Journal of Vascular Surgery Vemuri et al 1437
Volume 65, Number 5

Fig 5. Preoperative and follow-up functional outcomes measures are shown for 40 patients with arterial
thoracic outlet syndrome (TOS), comparing patients with vascular and nonvascular presentations and the entire
group. A, Disability of the Arm, Hand and Shoulder (DASH) scores. B, Cervical-Brachial Symptom Questionnaire
(CBSQ) scores. C, McGill Pain scores. Data represent the mean 6 standard error of the mean (SEM) for each
group. Comparisons were made by two-tailed, unpaired t-tests with the Welch correction. NS, Not significant.
1438 Vemuri et al
resonance imaging, or catheter-based arteriography is
recommended before surgical treatment or conserva-
tive management.
However, routine imaging beyond plain radiographs
does not appear necessary in all patients with neuro-
genic TOS, where the likelihood of identifying fixed sub-
clavian artery pathology is extremely low in the absence
of a bony abnormality. Furthermore, noninvasive vascular
laboratory studies and duplex imaging do not appear to
offer sufficient accuracy or consistency to be useful in
evaluating patients with neurogenic TOS or those with
suspected arterial TOS. Noteworthy in this study was
that 53% of patients with a nonvascular presentation
and preoperative subclavian artery dilatation had dilata-
tion of <100% at the time of surgical treatment and thus
did not undergo arterial reconstruction compared
with only 13% of patients with a vascular presentation.
Long-term follow-up in those not having arterial re-
construction revealed no further dilatation or vascular
complications, indicating that thoracic outlet decom-
pression alone is sufficient to prevent progression of sub-
clavian artery pathology in this situation. We recommend
that such patients undergo periodic follow-up imaging
with MRA or CTA to monitor for dilatation in the first
few years, but this is probably not needed beyond 3 to
5 years of surgical treatment.
Patients with a vascular presentation of arterial TOS
have the greatest potential for disability and poor out-
comes, which are usually dictated by the extent of distal
thromboembolism and ischemia before surgical treat-
ment.6-18 We have recommended that when feasible,
those with acute or subacute upper extremity ischemia
initially undergo surgical treatment for distal thrombo-
embolism, followed by anticoagulation. Any additional
imaging evaluation is then performed, followed by
staged surgical treatment for arterial TOS as a secondary
procedure, days to weeks after thromboembolectomy.
This approach was illustrated by eight patients in the
present study, representing 38% of those presenting
with thromboembolism, whereas the remainder pre-
sented with chronic digital ischemia or emboli not
amenable to thromboembolectomy. We also had two
patients in this series who presented with posterior cere-
bral stroke as a result of retrograde thromboembolism
from the subclavian artery, along with upper extremity
symptoms. Posterior stroke is the most devastating
vascular complication of arterial TOS and must be kept
in mind during diagnostic evaluation and treatment
planning.26,27
In addition to supraclavicular thoracic outlet decom-
pression, 26 patients underwent subclavian artery recon-
struction with an interposition bypass graft. This was
usually conducted from the supraclavicular exposure
alone, but when necessary, an infraclavicular incision
was added to obtain distal control of the axillary artery.
Our preference in this series was to use biological
Journal of Vascular Surgery
May 2017
conduits, such as cryopreserved femoral artery or vein,
for subclavian revascularization given the ease of use
and flexibility of these conduits and the recognition
that bypass grafts in this location are subject to a high
degree of motion with use of the upper extremity.
It has also been our practice to obtain routine intrao-
perative arteriography to assess the subclavian artery
reconstruction. During follow-up we found acceptable
patency rates with subclavian bypass grafts in this series,
but several patients exhibited bypass graft occlusion.
Each of these individuals had a complicated vascular
presentation, and two had previously undergone subcla-
vian artery revascularization elsewhere before referral,
emphasizing the management challenges presented
by some patients with arterial TOS.
CONCLUSIONS
Arterial TOS is a rare condition with the potential for
life- and limb-threatening thromboembolic complica-
tions. This single-institution series demonstrates the
diverse clinical presentation of arterial TOS coincident
with a wide spectrum of bony and arterial pathology.
This study also indicates that current surgical protocols
can achieve excellent outcomes for this frequently
complicated subset of patients.
AUTHOR CONTRIBUTIONS
Conception and design: CV, LM, AA, RT
Analysis and interpretation: CV, LM, AA, RT
Data collection: CV, LM, AA, RT
Writing the article: CV, RT
Critical revision of the article: CV, LM, AA, RT
Final approval of the article: CV, LM, AA, RT
Statistical analysis: RT
Obtained funding: RT
Overall responsibility: RT
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Submitted Sep 8, 2016; accepted Nov 14, 2016.