TITLE:
Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome
AUTHORS:
Farid Gharagozloo
KEYWORDS:
Thoracic Outlet Syndrome, Robotic First Rib Resection, Neurogenic TOS, Venous TOS, Arterial TOS, Algorithm
JOURNAL NAME:
World Journal of Cardiovascular Surgery,
Vol.12 No.10,
October
11,
2022
ABSTRACT: Purpose: Historically the classification of Thoracic Outlet Syndrome
(TOS) has been based on symptoms rather than the underlying pathology. Therefore,
TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter
Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion
among medical practitioners, difficulty in making the diagnosis, and the poor results
with surgical intervention. Methods: The published papers from PubMed on
the newer understanding of the pathogenesis and the surgical treatment of TOS were
reviewed. Results: More recently TOS has been classified based on the underlying
pathologic entity. Based on this classification, patients who are suspected of having
TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the
result of “Subclavian Vein Compression Syndrome”. This classification has resulted
in more accurate diagnosis, better patient selection for surgery, and excellent
surgical results. This paper outlines the algorithm for making the appropriate diagnosis
in patients who present with neurovascular symptoms of the upper extremity and the
selection of the appropriate patients for surgery. Conclusion: Based on the
algorithm for surgical decision making, patients with Cervical Rib Disease should
undergo cervical exploration and resection of the pathologic entity which results
in compression of the brachial plexus or the subclavian artery in the neck. Patients
with Thoracic outlet Syndrome who are found to have extrinsic compression of the
subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic
MRA should undergo robotic first rib resection.