Surgical Treatment of Arterial Thoracic Outlet Syndrome
Arterial thoracic outlet syndrome (ATOS) is a rare but potentially devastating condition where extrinsic compression of the subclavian artery at the thoracic outlet results in embolization and thrombosis of the upper extremity arterial tree. Limb loss may occur as consequence of repeated embolization or delayed revascularization. Subclavian artery occlusion may result in retrograde propagation of thrombus with compromise of vertebral circulation and stroke. The presentations include acute limb-threatening ischemia, unilateral Raynaud, unilateral painful hand, and asymptomatic subclavian artery aneurysm or stenosis. Exam shows asymmetric pulses in upper extremity. Pallor of the hand and delayed capillary refill are common. Cyanosis and a cold hand may be mistaken for Raynaud. Loss of sensation, weakness, and pain indicate an urgent condition. Initial diagnosis is based on ultrasound exams. A chest x-rays may show a cervical rib. Computed tomography (CT) angiograms are best for demonstrating the relation of extrinsic compression to the arterial pathology. Catheter arteriograms may allow for evaluation of the extent of thrombus and initiation of thrombolysis. Surgical thrombectomy with balloon catheter effects rapid restoration of arterial circulation and may be ideal for cases of severe acute ischemia. Care should be taken to assess the proximal extent of the thrombus to avoid inadvertent embolization to the vertebral artery. Resection of cervical and first rib is most commonly required. Arterial reconstruction may be accomplished via open or endovascular technique depending on the condition of arteries. Outcomes are good with limb salvage and restoration of function.
