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Thoracic Outlet Syndrome Thoracic Outlet Syndrome Prof. T. Vidyasagaran HOD, Dept of Vascular Surgery Vascular Surgeon, Chennai. Prof. T. Vidyasagaran.

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Presentation on theme: "Thoracic Outlet Syndrome Thoracic Outlet Syndrome Prof. T. Vidyasagaran HOD, Dept of Vascular Surgery Vascular Surgeon, Chennai. Prof. T. Vidyasagaran."— Presentation transcript:

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2 Thoracic Outlet Syndrome Thoracic Outlet Syndrome Prof. T. Vidyasagaran HOD, Dept of Vascular Surgery Vascular Surgeon, Chennai. Prof. T. Vidyasagaran HOD, Dept of Vascular Surgery Vascular Surgeon, Chennai.

3 Definition Upper extremity symptoms due to compression of the neuro vascular bundle in the Thoracic Outlet Area Upper extremity symptoms due to compression of the neuro vascular bundle in the Thoracic Outlet Area TOS

4 95 % Neurogenic 1 % Arterial % Venous 95 % Neurogenic 1 % Arterial % Venous Vasculogenic TOS

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7 Three Spaces Scalene Triangle Costoclavicular space Pectoralis minor space TOS

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9 Predisposing Anatomic Factors ö Bony Congenital narrowing - Cervical 4.5 % Rudimentary rib Long C7 transverse process Acquired narrowing- Malunion Callus Exostosis or tumors ö Bony Congenital narrowing - Cervical 4.5 % Rudimentary rib Long C7 transverse process Acquired narrowing- Malunion Callus Exostosis or tumors Neurogenic TOS

10 Scalene Muscle ö Neck trauma - Primary cause ö Anatomy of muscle - Predisposing factor for nerve compression ö Splitting of SA ö Scalene minimus ö Interdigitation ö Middle scalene 58 % ö Neck trauma - Primary cause ö Anatomy of muscle - Predisposing factor for nerve compression ö Splitting of SA ö Scalene minimus ö Interdigitation ö Middle scalene 58 % SA SM BP A A Rib SA SM BP A A Rib cms Rib cms V V V V TOS

11 ö Automobile accidents Hyperextension neck injuries ö Repetitive stress injuries ö Automobile accidents Hyperextension neck injuries ö Repetitive stress injuries Neck Trauma Keyboard Jobs ö Arm ö Neck stretching Keyboard Jobs ö Arm ö Neck stretching Neurogenic TOS

12 Symptoms Young years 70 % Women Paresthesia All nervesCommonest UlnarLower chord MedianUpper chord Pain Headaches occipital Scapular pain TrapeziusDorsal scapular nerve Rhomboids Weakness Vascular - sympathetic response Young years 70 % Women Paresthesia All nervesCommonest UlnarLower chord MedianUpper chord Pain Headaches occipital Scapular pain TrapeziusDorsal scapular nerve Rhomboids Weakness Vascular - sympathetic response Neurogenic TOS

13 Clinical Diagnosis ö Supraclavicular muscle tenderness ö Tinels signs - specific signs ö AER - EAST ö Decreased sensation to light touch ö Adsons 50 % normal individuals 30 % of TOS ö Supraclavicular muscle tenderness ö Tinels signs - specific signs ö AER - EAST ö Decreased sensation to light touch ö Adsons 50 % normal individuals 30 % of TOS Positional Maneuvers Pulse deficit Positional Maneuvers Pulse deficit Neurogenic TOS

14 Diagnostic Tests ö Scalene muscle block 4 ml 1 % lignocaine ö ASM - Tender area cephalad ö 94 % - with surgical decompression ö Scalene muscle block 4 ml 1 % lignocaine ö ASM - Tender area cephalad ö 94 % - with surgical decompression Neurogenic TOS 2 cms above clavical 3 cms lateral to the midline 2 cms above clavical 3 cms lateral to the midline

15 ö X ray chest (upper thoracic) ö X Ray neck - AP - oblique cervical spine ö MRI ö X ray chest (upper thoracic) ö X Ray neck - AP - oblique cervical spine ö MRI Neurogenic TOS

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18 DD Neurological diseases ö Spinal cord tumor ö Multiple sclerosis Shoulder disorders ö Shoulder tendinitis ö Myositis Nerve compression syndrome ö Carpal tunnel guyen tunnel ö Cuboid tunnel epicondylitis Neurological diseases ö Spinal cord tumor ö Multiple sclerosis Shoulder disorders ö Shoulder tendinitis ö Myositis Nerve compression syndrome ö Carpal tunnel guyen tunnel ö Cuboid tunnel epicondylitis Neurogenic TOS Cervical spine pathology ö Cervical spine injury ö Disc herniation ö Spinal stenosis Sympathetic diseases ö Raynauds ö Reflex sympathetic dystrophy Cervical spine pathology ö Cervical spine injury ö Disc herniation ö Spinal stenosis Sympathetic diseases ö Raynauds ö Reflex sympathetic dystrophy

19 Treatment Non operative modalities ö Neck stretching ö Abdominal breathing ö Posture exercise ö Shoulder shrugs ö Lifting light weight ö Neck traction Non operative modalities ö Neck stretching ö Abdominal breathing ö Posture exercise ö Shoulder shrugs ö Lifting light weight ö Neck traction Strengthening Exercise Worsens Ineffective Neurogenic TOS

20 Surgery ö Failure of Conservative ö Disabling symptoms Work Recreation Daily living ö Symptoms more than a year ö Failure of Conservative ö Disabling symptoms Work Recreation Daily living ö Symptoms more than a year Neurogenic TOS

21 Decompression of brachial plexus Rib excision Scalenectomy Rib excision Scalenectomy Principles Neurogenic TOS

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24 Complications Less than 1 % Nerve Injuries Bleeding Lymph leakage Nerve Injuries Bleeding Lymph leakage Neurogenic TOS

25 ö Post stenotic dilatation ö Aneurysmal dilatation ö Thromboembolic complications ö Post stenotic dilatation ö Aneurysmal dilatation ö Thromboembolic complications Arterial TOS

26 Pathophysiology Significant Permanent Long standing ö Congenital or acquired bony abnormality ö 10 years older than neurogenic TOS Significant Permanent Long standing ö Congenital or acquired bony abnormality ö 10 years older than neurogenic TOS Arterial TOS

27 Diagnostic ö History ö Examination- Pulsatile SC mass - bruit ö Radiological - Cervical spine - Upper thoracic ö Duplex ö ArteriographyDSA Dynamic views ö Helical CTMRA ö Surgical exploration ö History ö Examination- Pulsatile SC mass - bruit ö Radiological - Cervical spine - Upper thoracic ö Duplex ö ArteriographyDSA Dynamic views ö Helical CTMRA ö Surgical exploration Arterial TOS

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32 Management Principles Surgery ö Compression ö Subclavian axillary artery lesions ö Distal tree status Surgery ö Compression ö Subclavian axillary artery lesions ö Distal tree status Arterial TOS

33 Reconstruction ö PSD with no intramural thrombosis - No intervention ö Tailoring subclavian artery ö Intimectomy with tailoring subclavian artery ö Vein patch closure ö ResectionPrimary repair Graft interposition ö PSD with no intramural thrombosis - No intervention ö Tailoring subclavian artery ö Intimectomy with tailoring subclavian artery ö Vein patch closure ö ResectionPrimary repair Graft interposition Arterial TOS

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39 Distal Embolism ö Multiple & diffuse ö Various ages ö Recent - Thromboembolectomy ö Old - Bypass ö Distal tree choked - Dorsal sympathectomy ö Multiple & diffuse ö Various ages ö Recent - Thromboembolectomy ö Old - Bypass ö Distal tree choked - Dorsal sympathectomy Arterial TOS

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42 Subclavian Axillary Vein Thrombosis Paget Schroetter Syndrome Primary Subclavian Axillary Thrombosis Paget Schroetter Syndrome Primary Subclavian Axillary Thrombosis Venous TOS

43 Incidence ö 1.4 % of all DVT ö 25 % of all upper DVT ö 1.4 % of all DVT ö 25 % of all upper DVT Venous TOS

44 Clinical Presentation ö Young males 2 : 1 ö Age 30 years ö Strenuous exercise - 75 % ö Dominant extremity % ö Associated neurogenic % ö Young males 2 : 1 ö Age 30 years ö Strenuous exercise - 75 % ö Dominant extremity % ö Associated neurogenic % Venous TOS

45 Diagnosis ö Clinical swelling ö Venous engorgement ö Sudden onset ö Duplex ö Venography ö MRV ö Radionuclide venography ö Clinical swelling ö Venous engorgement ö Sudden onset ö Duplex ö Venography ö MRV ö Radionuclide venography Venous TOS

46 Treatment ö Rest & Elevation ö Systemic anticoagulation ö Rest & Elevation ö Systemic anticoagulation Long Term Morbidity Venous TOS

47 Restore luminal patency Remove extrinsic compression Intrinsic stenosis Restore luminal patency Remove extrinsic compression Intrinsic stenosis

48 Venous TOS Thrombolytic Thrombectomy- with decompression

49 Thrombolytic ö Systemic ö Catheter directed - Venographic evaluation possible - Assess extrinsic compression immediately - Oral anticoagulation 3 months / 1 month - Decompression - Balloon angioplasty & stenting ö Systemic ö Catheter directed - Venographic evaluation possible - Assess extrinsic compression immediately - Oral anticoagulation 3 months / 1 month - Decompression - Balloon angioplasty & stenting Venous TOS

50 Presentation Duplex confirm Appropriate candidate Venography CD Thrombolysis Complete lysis Positional venography Complete lysis Positional venography EC TOD No EC Anticoagulation Intrinsic stenosis TOD + Vein patch angioplasty or balloon angioplasty stent TOD + Vein patch angioplasty or balloon angioplasty stent Venous TOS Incomplete lysis Algorithm

51 Incomplete Lysis Short occlusion Operative thrombectomy or Balloon AP Stent Operative thrombectomy or Balloon AP Stent Long occlusion Anticoagulation Persistent symptoms Surgery Venous TOS Algorithm Failure

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53 Trinity Oration

54 THANK YOU

55 Scalene Triangle Commonest site of Nerve compression Brachial plexus Subclavian artery Commonest site of Nerve compression Brachial plexus Subclavian artery TOS

56 Costoclavicular Artery Vein Nerve Artery Vein Nerve TOS

57 Seldom involved in TOS Pectoralis Minor Space TOS


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