Thoracic Outlet Syndrome

Archie R McGowan, MD
Benjamin B Faitelson MD

Presentation

Imaging Findings

A cut film venogram demonstrates complete occlusion of the patient's left subclavian vein (arrow) where it crosses the first rib. Also of importance are the multiple dilated collateral vessels suggesting chronicity.

The second image demonstrates an attempt at angioplasty of this compressed and thrombosed vessel (arrow).

Digital venography of the contralateral side shows bilaterality of the subclavian vein thrombosis (arrow) (although the patient is asymptomatic on the right side).

Diagnosis

Discussion

Subclavian vein thrombosis has in the past been divided into primary and secondary, with secondary representing thrombosis from obvious etiology such as direct invasion by malignancy or by venous catheterization. Primary thrombosis has also been called idiopathic, spontaneous and effort thrombosis (as it is often seen after exertion).

Subclavian vein thrombosis represents only 3.5% of cases of thoracic outlet syndrome. Venous thrombosis is seen three times more frequently on the right than the left venous system, but bilateral involvement also occurs frequently. Thrombosis is believed to be caused by repetitive trauma from compression.

The compressing structures include the clavicle, the first rib, subclavian muscles, costoclavicular ligament and the anterior scalene. Common causes of congenital extrinsic compression of the vein include cervical ribs and congenital or acquired abnormalities of the first rib or clavicle (such as a fusion) as well as congenital bands and the pectoralis minor tendon. If hypertrophied, the anterior scalene can produce venous compression within the scalene triangle.

Diagnostic studies should be bilateral even if symptoms are unilateral; contralateral disease is often found. Therapy must address both extrinsic and intrinsic lesions affecting the vein. Surgical decompression of veins within the scalene triangle is achieved by anterior rib resection, anterior scalene release and in some cases clavicular resection. Acute thrombus can be managed by anticoagulation or thrombolytic drugs. Chronic venous stenosis or webs can be treated with percutaneous angioplasty or surgery. These maneuvers seldom produce a lasting result, and relief of symptoms often depends on increases in the level of collateral flow.

References

2. Sanders R, Haug C. Subclavian vein obstruction and thoracic outlet syndrome: a review of etiology and management. Annals of Vascular Surgery 1990; 4(4):397-409.

3. Gloviczki P, Hollier L. Axillary-subclavian venous occlusion: the morbidity of a non-lethal disease. Journal of Vascular Surgery 1986; 4(4):333-7.

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