Current trends in the treatment of venous thoracic outlet syndrome: a comprehensive review

The term ‘thoracic outlet syndrome’ (TOS) represents a variety of disorders caused by the compression of nerves, arteries and veins as they exit the thorax and enter the axilla. Three basic syndromes are reported according to the involved anatomic structures: neurogenic, venous and arterial. Occasionally, the neurological and arterial syndromes may coexist in the same patient. However, for ease of understanding, each of these syndromes should be conceptualized as distinct clinical entities for they have characteristic differences in clinical presentation, diagnostic workup and treatment. Venous TOS, which is the topic of this review, can be further divided into two categories, the thrombotic and the less common nonthrombotic venous TOS. Thrombotic venous TOS, also known as Paget–Schroetter syndrome, specifically refers to primary axillosubclavian vein thrombosis [1]. Another term for this syndrome is ‘effort thrombosis’, as it is frequently associated with repetitive activities of arm elevation or exertion over a long period of time [2]. Sir James Paget first described a spontaneous thrombosis of the subclavian vein in 1875 [3], and in 1884 von Schroetter correlated this entity with direct damage of the vein caused by muscular strain [4]. The eponym ‘Paget–Schroetter syndrome’ first appeared in 1948 when it was coined by Hughes, an English surgeon who described this clinical condition in more detail [5]. Nonthrombotic venous TOS represents an intermittent/positional venous obstruction usually due to external compression, without the presence of intraluminal thrombus. Patients generally have normal venograms at rest, but develop varying degrees of extrinsic compression and venous collateral drainage with the arm abducted [6]. The natural history of these patients is not clear; however, some believe it may be a precursor of Paget–Schroetter syndrome. This review focuses on the anatomy and pathophysiology associated with venous TOS, the diagnostic workup and proposed treatment. The venous variant of TOS in many ways is less controversial than the neurogenic variety and can be objectively identified by clinical examination, ultrasonography or venography. However, controversies remain regarding the most appropriate treatment, the need for thoracic outlet decompression, the role of thrombolytic therapy, and the indications for balloon angioplasty or stenting. Most importantly, significant controversy exists regarding the timing of treatment during the natural course of the disease. We describe treatment options and suggest an algorithm for appropriate, safe and effective patient management.