Novel Surgical Approach Results in Significant Improvement of Symptoms for Often Misdiagnosed Thoracic Outlet Syndrome

Venous thoracic outlet case with effort thrombosis.

Venous thoracic outlet case with effort thrombosis. The patient has undergone first rib resection. Note area of residual venous stenosis which responded to venoplasty (middle image).

The upper extremity disorder thoracic outlet syndrome (TOS) is frequently misdiagnosed, as it appears in a younger patient population, typically between 20 and 50 years old, and is easily mistaken for a musculoskeletal disorder. Physical therapy (PT) is often the initial treatment for patients without blood clots; two-thirds with the neurogenic form of TOS can be treated with PT alone. However, a recent retrospective study of 538 patients during a 10-year period who underwent first rib resections (FRRs) for treatment of neurogenic, venous, and arterial TOS, showed that 93 to 96 percent experienced improved or fully resolved symptoms.1

TOS can be uncovered with noninvasive diagnostic testing through a detailed medical history, physical examination with manipulation of the arm and shoulder, chest X-ray and a vascular laboratory study. In neurogenic TOS, the most common form of the disorder, patients often present with pain or numbness in the arm or hand resulting from a trauma. Patients with venous TOS, often athletes, can exhibit swelling of the arm where the rib compresses the subclavian vein as a result of muscular buildup. Arterial TOS is most often found in patients with an extra cervical rib which compresses the subclavian artery. This can reduce blood flow and cause claudication and even lead to embolization at times, or a “cold arm.”

FRR surgery is usually required of patients who experience deep vein thrombosis (DVT) as a result of TOS. Amy Reed, M.D., Penn State Hershey Heart and Vascular Institute, has performed FRR surgery using multiple approaches, including supraclavicular, paraclavicular, and transaxillary. “While all FRR surgeries are associated with an elevated risk of damage to the nearby structures including veins and arteries, transaxillary FRR surgery carries less risk of injury to the phrenic nerve that controls the diaphragm,” according to Reed. She also cites minimally invasive instrumentation as future methods of reducing risk.

This rare condition requires special surgical training; patients tend to be referred to academic medical centers. To improve diagnosis rates, Reed emphasizes, “An otherwise healthy young patient who presents with an upper extremity DVT should be evaluated for venous thoracic outlet disorder.”

Amy Reed, M.D., FACSAmy Reed, M.D., FACS
Professor, Surgery
Chief, Vascular Surgery
PHONE: 717-531-8898
FELLOWSHIPS: Vascular surgery, Harvard Brigham and Women’s Hospital, Boston, Massachusetts and Mayo Clinic, Rochester, Minnesota
RESIDENCIES: Vascular surgery and general surgery, Brigham and Women’s Hospital, Boston, Massachusetts
MEDICAL SCHOOL: University of Wisconsin Medical School, Madison, Wisconsin


  1. Orlando MS, Likes KC, Mirza S, Cao Y, Cohen A, Lum YW, Reifsnyder T, Freischlag JA. A Decade of Excellent Outcomes after Surgical Intervention in 538 Patients with Thoracic Outlet Syndrome. J Am Coll Surg. 2015 Jan 15. pii: S1072-7515(15)00027-7. doi: 10.1016/j.jamcollsurg.2014.12.046. [Epub ahead of print].

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