Thoracic outlet syndrome

Case contributed by Derrick Barr

Presentation

This patient is a 35 year old woman who presented to the emergency department for shortness of breath. She denies having any past medical conditions, denies taking medications, and has no reported allergies.

Patient Data

Age: 35 years
Gender: Female

In addition, she states that for the past several weeks her right arm and hand have been throbbing and they have the sensation of fullness when she plays tennis, does yard work, or lifts her right arm above her head repeatedly. She denies recent trauma, infection, fevers or weakness.

CT

Compression of the subclavian vein between the first rib and clavicle was confirmed on CT, and the DVT was redemonstrated and located immediately distal to this compression. Furthermore, the subclavian artery was compressed at the same location as the vein confirming a rare diagnosis of arterial thoracic outlet syndrome (aTOS) with venous thoracic outlet syndrome (vTOS) complicated by upper limb deep venous thrombosis (DVT) and resultant pulmonary embolism (PE). 

Case Discussion

This patient presented with shortness of breath and was diagnosed with a pulmonary embolism using CTA. Ultrasonography identified a DVT in the right axillary vein which was resumed to be the origin of the embolus. The vein was non-compressible during the scan with an area of echogenic distension and severely reduced blood flow consistent with DVT. To assess for thoracic outlet syndrome (TOS) and further characterize the axillary DVT a CT evaluation was performed using a TOS protocol. After the diagnosis of effort thrombosis (Paget-Schrötter syndrome) was confirmed by CT, this patient underwent right anterior scalenectomy to treat the subclavian vessel compression.

Neurogenic thoracic outlet syndrome (nTOS) is by far the most common subtype of TOS accounting for 90% of cases, whereas venous (vTOS) and arterial thoracic outlet syndromes (aTOS) comprise 3% and 1% of cases respectively 1. Paget-Schrötter syndrome is activity-induced deep vein thrombosis of the upper extremity which affects 1 in 50,000 people annually 2. This patient developed the DVT in the setting of activity (i.e. tennis, yard work, etc.) with no other comorbidities. Definitive treatment of Paget-Schrötter syndrome or thoracic outlet syndrome is decompression of the thoracic outlet, which was successful in this patient.

 

This case was contributed by Derrick L. Barr, and Bradley S. McDonald

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