Vascular compression syndromes

Thoracic outlet syndrome

Compression of the nerves, vein or artery supplying the arm as they pass between the collarbone, the first rib and the scalene muscles. It mainly affects young, active people, and its venous form, Paget-Schroetter syndrome, is an emergency that should be treated promptly.

Three different forms

Who does it affect?

Mainly young people who make repeated movements with their arms above their head: swimmers, racket, throwing and gym athletes, and jobs that require this posture. Individual anatomy (cervical rib, fibrous bands, well-developed scalene muscles) and previous neck injuries also play a part.

Diagnosis

1. Examination with provocative manoeuvres of the arm and neck.
2. Dynamic duplex ultrasound of the subclavian vein and artery, at rest and with the arm raised.
3. CT or MR angiography with manoeuvres, to see the exact point of compression.
4. In the venous form, venography, which also allows the clot to be treated in the same procedure.
5. In the neurogenic form, nerve conduction studies and rehabilitation assessment. The reporting standards of the US Society for Vascular Surgery require at least three of four criteria: local symptoms in the neck area, symptoms of nerve compression in the arm, no other cause to explain them, and a positive response to an anaesthetic block of the scalene muscle.

Treatment

Venous form (Paget-Schroetter)

The aim is to remove the clot and free the vein so that it is not compressed again. A 2023 systematic review and meta-analysis of 2,653 patients found that 54% of those treated with anticoagulation alone were symptom-free, compared with 96% of those who received catheter-directed thrombolysis and first rib resection, although the certainty of the evidence is very low.

For this reason, in young and active patients, the evidence supports a combined approach: dissolving or removing the clot by the endovascular route and then decompressing the thoracic outlet by resecting the first rib. I have taken part in studies on the long-term results of transaxillary decompression in this syndrome.

Neurogenic form

The first step is specific physiotherapy and correction of posture and exertion. Decompression surgery is reserved for cases that do not improve after properly conducted conservative treatment.

Arterial form

Requires surgery: decompression of the thoracic outlet (resection of the cervical or first rib) and repair of the artery if it is damaged or dilated.

Frequently asked questions

My arm suddenly swelled up after training. What should I do?

Go to A&E. Sudden swelling of the arm, with a bluish colour and prominent veins, may be a subclavian vein thrombosis, and the best results are achieved when it is treated early.

Does the first rib always have to be removed?

No. In the neurogenic form, treatment starts with physiotherapy. In the venous form with thrombosis, decompression improves results because it removes the cause of the compression.

Will I be able to play sport again?

That is precisely the aim of treatment. When you can return depends on the form of the syndrome and the treatment carried out.

References

Patient information reviewed by Dr Óscar Merino, vascular surgeon. It does not replace an individual medical assessment.