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\begin{document}

\title{Duplex Ultrasound in the Evaluation of Venous and Arterial Thoracic
Outlet Syndrome}



\author[1]{Jian Hu}%
\author[1]{Tarun Tewatia}%
\author[1]{Kartikeya  Kashyap}%
\author[1]{John Wilson}%
\author[1]{Victor Farah}%
\author[1]{Todd Franco}%
\author[1]{Vinh Nguyen}%
\affil[1]{Allegheny Health Network}%


\vspace{-1em}



  
  \date{May 07, 2024}


\begingroup
\let\center\flushleft
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\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Thoracic outlet syndrome (TOS) is caused by neurovascular bundle
compression in the thoracic outlet space. Three pertinent structures may
be compressed: brachial plexus, subclavian artery, and subclavian vein.
Clinical presentation may be variable depending on the anatomical
structure involved. We report a 36-year-old man with chronic recurrent
pressure-quality left chest discomfort. Comprehensive cardiac
investigations were nonrevealing. A venous and arterial duplex
ultimately revealed dynamic venous and arterial compression. Our paper
is to illustrate the sonographic approach to evaluate vascular
compression in the thoracic outlet. We review the mechanisms of
compression, and examination maneuvers to facilitate a Doppler-based
diagnosis.%
\end{abstract}%



\sloppy


\textbf{Title:}

Duplex Ultrasound in the Evaluation of Venous and Arterial Thoracic
Outlet Syndrome

\textbf{Running head:}

Duplex in Thoracic Outlet Syndrome

\textbf{Authors} :

Jian Hu\textsuperscript{1} MD, PhD, Robert
Biederman\textsuperscript{2}MD, Kartikeya Kashyap\textsuperscript{2} MD,
John Travis Wilson\textsuperscript{2} MD, Victor
Farah\textsuperscript{2} MD, Todd Franco\textsuperscript{3} DO, Vinh Q.
Nguyen\textsuperscript{2} MD

\textbf{Affiliations of authors:}

1. Department of Internal Medicine, Allegheny General Hospital,
Allegheny Health Network, Pittsburgh, U.S.A. Fax: none

2. Department of Cardiovascular Medicine, Allegheny General Hospital,
Allegheny Health Network, Pittsburgh, U.S.A. Fax: none

3. Department of Sports Medicine, Allegheny General Hospital, Allegheny
Health Network, Pittsburgh, U.S.A. Fax: none

\textbf{Corresponding author:}

Vinh Q. Nguyen, MD

Department of Cardiovascular Medicine, 17\textsuperscript{th} Floor,
South Tower, Allegheny General Hospital, 320 E. North Ave, Pittsburgh,
PA 15212

Email: vinh.nguyen@ahn.org

\textbf{Statement on Compliance with Ethical Standards:}

\textbf{Funding:} This study was not supported by any funding.

\textbf{Conflict of Interest:} The authors declare that they have no
conflict of interest.

\textbf{Duplex Ultrasound in the Evaluation of Venous and Arterial
Thoracic Outlet Syndrome}



\section*{Abstract}

{\label{abstract}}

Thoracic outlet syndrome (TOS) is caused by neurovascular bundle
compression in the thoracic outlet space. Three pertinent structures may
be compressed: brachial plexus, subclavian artery, and subclavian vein.
Clinical presentation may be variable depending on the anatomical
structure involved. We report a 36-year-old man with chronic recurrent
pressure-quality left chest discomfort. Comprehensive cardiac
investigations were nonrevealing. A venous and arterial duplex
ultimately revealed dynamic venous and arterial compression. Our paper
is to illustrate the sonographic approach to evaluate vascular
compression in the thoracic outlet. We review the mechanisms of
compression, and examination maneuvers to facilitate a Doppler-based
diagnosis.

\textbf{Key word} : thoracic outlet syndrome; duplex ultrasound;
vascular imaging



\textbf{Duplex Ultrasound in the Evaluation of Venous and Arterial
Thoracic Outlet Syndrome}

\section*{Introduction:}

{\label{introduction}}

Thoracic outlet syndrome (TOS) is a constellation of symptoms in the
shoulder and upper extremity that may present as pain, dysesthesia,
weakness, edema, and pallor resulting from total or partial compression
of the neurovascular bundle exiting the space between the first rib and
the clavicle, known as the thoracic outlet. TOS is classified into three
subgroups according to its pathophysiology: neurogenic TOS (nTOS),
arterial TOS (aTOS), and venous TOS (vTOS). Among them, nTOS accounts
for more than 90\% of the cases, followed by vTOS accounting for 3-5\%,
and aTOS accounting for 1-2\% \textsuperscript{{[}1{]}}. Venous TOS, an
uncommon subtype, occurs as a result of extrinsic compression and
subsequent stenosis of the subclavian vein. It is a predominantly
unilateral and is often associated with repetitive upper extremity
motion. According to previous reports, anomalous anatomy, repetitive
movement-induced swelling with microhemorrhage and subsequent fibrosis,
compressive soft tissue masses, deep-venous thrombosis can be initiators
of vTOS \textsuperscript{{[}2-5{]}}. If the vTOS is caused by a
spontaneous deep vein thrombosis (DVT), it is referred to as Paget-von
Schr\selectlanguage{ngerman}öetter Syndrome.

\textbf{Case Illustration:}

A 37-year-old man with a past medical history of pulmonary sarcoidosis,
melanoma in remission, and former tobacco smoking presented with
recurrent pressure-quality left chest discomfort with radiation to neck
and shoulder, accompanied by left arm numbness and tingling,
intermittently aggravated by shoulder movement. Physical examination
revealed tenderness along the medial scapula, reduced abduction of the
left shoulder, minimal pain with impingement testing including Neer and
Hawkins exam, negative cross-body and O'Brien's exams (Table 1).
Complete blood count, comprehensive metabolic profile, and cardiac
biomarkers were normal. Cardiac work up was negative, including
electrocardiogram and stress echocardiogram. Computed topography of
chest and abdomen showed noncompressive lung and liver lesions, in
keeping with known sarcoidosis. Magnetic resonance imaging (MRI) of
cervical spine, shoulder, and brachial plexus were negative. His
symptoms failed to improve with physical therapy.

A vascular duplex of left upper extremity was performed showing
compression of both the subclavian vein and artery. The subclavian vein
was assessed with color and spectral Doppler in the neutral position, at
90° abduction, and at 180° abduction. At both 90° and 180° abduction,
there was loss of cardiac pulsatility and respiratory phasicity, but
continuous flow remained, indicating compression without obstruction
(Figure 1). Halstead maneuver was also performed to illicit obstruction
(Table 1). This position is performed by adopting a military posture
with the arms pulled back and chest protruded forward. There is complete
flow obstruction provoked by this maneuver (Figure 2). Interrogation of
the subclavian artery was performed with shoulder abduction and Halstead
maneuver. Diminished peak systolic velocities and pulse volume
recordings with provocation indicate arterial compression (Figures 3 and
4).

The patient failed conservative therapy, including non-steroids
anti-inflammatory drugs (NSAIDS), Lidocaine patch, and physical therapy.
He underwent left thoracic outlet decompression with trans-axillary
resection of the first rib and division of the anterior scalene muscle
(Figure 5). Three months after surgery, he had drastic improvement in
symptoms with near complete resolution.

\section*{Discussion:}

{\label{discussion}}

TOS is usually caused by extrinsic compression and subsequent stenosis
of the neurovascular structure. An anatomical abnormality is the
typically fundamental prerequisite, including a cervical rib, anomalous
first rib, or anomalous scalene muscle \textsuperscript{{[}6{]}}.
Additionally, injuries such as hyperextension/flexion injury of neck and
bony fracture have been described \textsuperscript{{[}7, 8{]}}.
Thrombosis and tumor are also potential etiologies. The vTOS composed of
3-5\% cases of TOS. It is more common in younger (aged 14-45),
able-bodies individuals, and most often affects the dominant upper
extremity \textsuperscript{{[}9{]}}. The vTOS is also grouped into 3
categories: intermittent positional stenosis/obstruction, secondary
subclavian vein thrombosis due to catheter placement, and effort
thrombosis \textsuperscript{{[}3{]}}.

The symptoms of nTOS include pain, dysesthesia, numbness, and weakness
involving the distribution area of C5 through T1 brachial plexus nerves.
The aTOS can present with hand ischemic symptoms like pain, pallor,
paresthesia, and coldness. The vTOS presents with upper extremity edema,
accompanied by pain and cyanosis. Symptoms may be atypical and elusive,
as illustrated in our patient with recurrent chest pressure,
masquerading as angina pectoris. A clue to diagnosis was the precipitant
of symptoms triggered by arm movement. As such, he was referred for an
upper extremity venous duplex with examination maneuvers to temporarily
occlude the neurovascular structure. Electrodiagnostic testing via nerve
conduction and electromyography (EMG) are indicated for suspected nTOS.
For vTOS and aTOS, Doppler ultrasound is the primary test of choice due
to real-time assessment of dynamic Doppler signals associated with
compressive maneuvers, yielding a high sensitivity and
specificity\textsuperscript{{[}10{]}}. Secondary tests include CT or MRI
to define anatomical defects, such as prominent cervical rib or
compressive tumors and their anatomical relationship to the thoracic
outlet\textsuperscript{{[}10{]}}.

Treatment strategy of TOS depends on the underlying etiology, and can
involve conservative or surgical measures. Cervical rib or anomalous rib
without symptoms only need observation. Therapeutic strategies for nTOS
include physical therapy with option for interscalene injection,
corticosteroids, and botulinum toxin type A. Anticoagulation can be
given for thrombosis complicating VTOS or aTOS. Surgical intervention
such as thoracic outlet decompression remains the final method
conservative management fails. Surgical intervention is often the
initial approach for vTOS and aTOS in current practice, with the first
rib being resected to decompress the brachial plexus. The procedure is
usually performed by transaxillary, supraclavicular, or infraclavicular
techniques. Blocking the scalene muscle or pectoralis minor may be done
to predict the effect of surgery.

\textbf{Conclusion:}

Buried among a long list of different diagnoses for atypical chest pain
is TOS, and a heightened clinical suspicion is an absolute prerequisite.
There are a number of physical examination maneuvers to illicit
symptoms. If concern remains, a duplex ultrasound with provocative
maneuvers can be an efficient and invaluable tool to solidify the
diagnosis.

\textbf{References:}

1. Freischlag, J. and K. Orion, ``Understanding thoracic outlet
syndrome''. \emph{Scientifica (Cairo)} , 2014. 2014: p. 248163.

2. Ibrahim, R., et al., ``Paget-Schroetter syndrome in the absence of
common predisposing factors: a case report''\emph{.} \emph{Thromb J} ,
2017. 15: p. 20.

3. Mirza, A.K., et al., ``Soft Tissue Neoplasms Causing Apparent Venous
Thoracic Outlet Syndrome''\emph{.} \emph{Ann Vasc Surg} , 2017. 42: p.
306 e1-306 e4.

4. Yuschak, E., F. Haq, and S. Chase, ``A Case of Venous Thoracic Outlet
Syndrome: Primary Care Review of Physical Exam Provocative Tests and
Osteopathic Manipulative Technique Considerations''\emph{.Cureus,} 2019.
11(6): p. e4921.

5. Jones, M.R., et al., ``Thoracic Outlet Syndrome: A Comprehensive
Review of Pathophysiology, Diagnosis, and Treatment''\emph{.} \emph{Pain
Ther,} 2019. 8(1): p. 5-18.

6. Halsted, W.S., ``An Experimental Study of Circumscribed Dilation of
an Artery Immediately Distal to a Partially Occluding Band, and Its
Bearing on the Dilation of the Subclavian Artery Observed in Certain
Cases of Cervical Rib''\emph{.} J \emph{Exp Med} , 1916. 24(3): p.
271-86.

7. Almeida, D.F., R.D. Meyer, and S.J. Oh, ``True neurogenic thoracic
outlet syndrome in a competitive swimmer: a case report of this rare
association''\emph{.} \emph{Arq Neuropsiquiatr} , 2007. 65(4B): p.
1245-8.

8. Katirji, B. and R.W. Hardy, Jr., ``Classic neurogenic thoracic outlet
syndrome in a competitive swimmer: a true scalenus anticus
syndrome''\emph{.} \emph{Muscle Nerve} , 1995. 18(2): p. 229-33.

9. Maru, S., et al., ``Thoracic outlet syndrome in children and young
adults''\emph{.} \emph{Eur J Vasc Endovasc Surg} , 2009. 38(5): p.
560-4.

10. Demondion, X., et al., ``Imaging assessment of thoracic outlet
syndrome''\emph{.} \emph{Radiographics} , 2006. 26(6): p. 1735-50.

Table 1: Diagnostic maneuvers:\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Test\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Maneuver\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
Interpretation\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Special tests for TOS\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Special tests for TOS\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Special tests for TOS\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Adson's test}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
The shoulders are adducted to 30\selectlanguage{ngerman}° in fully extended position. The neck
is extended and turned towards symptomatic side. With the patient taking
and holding deep breath, the radial artery is palpated and compared to
baseline.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: diminished or loss of radial artery pulsation.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Cyriax release test}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
With patient in sitting or standing position, the forearms is grasped
from under, the elbows is held at 80\selectlanguage{ngerman}° of flexion with the forearms and
wrists in neutral. The trunk is leaned posteriorly and the shoulder
girdle is passively elevated. This position is held for up to 3
minutes.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: paresthesia and/or numbness (release phenomenon) occur,
including reproduction of symptoms.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Halstead maneuver} (costoclavicular maneuver or exaggerated
military brace test)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
With patient in standing position, both shoulders are drawn back, the
humerus is extended back, and the chest is protruded forward. The radial
artery is palpated and compared to baseline.\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Positive test: diminished or loss of radial artery pulsation.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Roos test} (Elevated arm stress test)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Both shoulders are adducted to 90\selectlanguage{ngerman}°, then the elbows are flexed to 90°.
Hands are pumped over 3 minutes.\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Positive test: symptoms reproduced; inability to complete test due to
symptom limitation; arm pallor in aTOS; cyanosis and swelling in
vTOS.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Supraclavicular pressure}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Examiner places fingers between the anterior scalene and upper trapezius
muscle, and squeeze for 30 seconds.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: paresthesia indicates brachial plexus compression through
the scalene triangle.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Wright test} (hyperabduction test)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
With patient in sitting position, the arm is passively brought into
abduction and external rotation to 90\selectlanguage{ngerman}° without tilting the head, the
elbow is flexed no more than 45°, then the arm is held for 1
minute.\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Positive test: decrease in the radial pulse and/or reproduction of the
patient's symptoms.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Other tests in the article\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Other tests in the article\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Other tests in the article\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Cross-body test}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
The shoulder is forward flexed to 90\selectlanguage{ngerman}°, then adducted horizontally across
the chest.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: pain~over the acromioclavicular joint, indicating
acromioclavicular joint degeneration/arthritis.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Hawkins test}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
The patient's arm is placed in 90\selectlanguage{ngerman}° of shoulder flexion with the elbow
flexed to 90° and then the arm is internally rotated.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: ~pain with internal rotation, indicating subacromial
impingement.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Neer test}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
With patient in standing position and arm at side of body with elbow
fully extended, the arm is internally rotated and forcefully moved
through the full range of forward flexion or until reports of
pain.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: pain in the anterior -- lateral aspect of the shoulder,
indicating subacromial impingement.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{O'Brien's test}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
With the patient in sitting or standing, the arm is placed in 90\selectlanguage{ngerman}° of
shoulder flexion and 10-15° of horizontal adduction, then the shoulder
is fully internally rotated and the elbow is pronated with a distal
stabilizing force is applied by examiner as the patient is applying an
upward force. The test is then repeated but with the arm in neutral
rotation.\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Positive test: pain and/or clicking when the arm is in full internal
rotation but not when the arm is in neutral rotation, indicating labral
(SLAP Lesion) or acromioclavicular lesions.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig1/Fig1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig2/Fig2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig3/Fig3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig4/Fig4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig5/Fig5}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

