DIAGNOSIS AND MANAGEMENT OF ARTERIAL COMPRESSION AT THE THORACIC OUTLET

Neurovascular compression syndromes at the thoracic outlet generally p resent with predominantly arterial, venous, or neurogenic symptoms. Th e arterial abnormalities produce unique problems in diagnosis and mana gement, and usually affect young, otherwise healthy, active individual s. Between 1984 and 1995 23 patients presented to our facility, with a cute symptoms of arterial occlusion or embolization, found to be origi nating from the axillosubclavian arterial segment. The group comprised 14 females and nine males, ranging from 15 to 74 years, with an avera ge age of 37 years. There were seven competitive athletes, three indus trial workers, and 13 home, office, or service workers. The most sever e presenting symptoms, occurring alone or in combination, and ranked i n order of frequency observed, were: arm 'claudication' (74%), hand is chemia (48%), and digital gangrene (44%). Transaxillary thoracic outle t decompression was undertaken in 22 cases. This was combined with art erial reconstruction in 11 cases and sympathectomy for ischemic causal gia in seven cases. Transaxillary resection of a cervical rib was acco mplished in 8 cases. There was one postoperative graft occlusion (PTFE ), corrected by thrombectomy, with cumulative secondary patency (to 64 months), and one secondary embolic occlusion. Excepting the two secon dary procedures, no patient had recurrent symptoms at a mean follow-up of 61 months. Effective and durable correction of the axillosubclavia n arterial compressive abnormalities requires adequate thoracic outlet decompression, and anatomic vascular reconstruction when necessary. F ailed prior procedures were a consequence of inaccurate diagnosis, fai lure to identify and correct the proximal embolizing arterial lesion, or inadequate decompression. Unilateral Raynaud's symptoms require met iculous investigation for arterial compression at the thoracic outlet with careful interpretation of subtle angiographic findings.