Thoracic Outlet Center

The Heart & Vascular Institute’s Thoracic Outlet Center brings together a team of specialists focused on early detection of Thoracic Outlet Syndrome that allows patients to avoid surgery. In most cases, physical therapists from the Hartford HealthCare Rehabilitation Network will oversee a treatment program based on your symptoms.

Thoracic Outlet Syndrome, a medical term to describe compression of blood vessels or nerves between the lower neck and upper chest -- an area known as the thoracic outlet – sometimes requires surgery. Our surgeons have special training for those rare cases of TOS that affect blood vessels (your arteries or veins).

“Our goal,” says Dr. Mario Katigbak, a Heart & Vascular Institute thoracic surgeon and chief of thoracic surgery at Hartford Hospital, “is to provide a comprehensive evaluation and treatment plan.” 


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The Condition


Thoracic Outlet Syndrome And The Dominant Arm

Thoracic Outlet Syndrome is often caused by repetitive overhead arm motion -- several Major League Baseball pitchers have had surgery for TOS – so the syndrome typically affects the dominant arm only. That’s why Bilateral Thoracic Outlet Syndrome, which would require surgery on the opposite side, is rare.

Here’s how treatment progresses, depending on the severity of your condition:

  1. Physical therapy: The standard first option.
  2. Pain management: Anti-inflammatories and muscle relaxants.
  3. Surgery: Decompression of the thoracic outlet syndrome via a supraclavicular (above the clavicle) incision.

Most people with Neurogenic-type Thoracic Outlet Syndrome (nTOS) are treated conservatively.

“Physical and occupational therapy are important parts of conservative management,” says Dan Fisher, a lead Thoracic Outlet Syndrome physical therapist at the Hartford HealthCare Cardiac Rehabilitation Network. “TOS can present very differently from one person to the next. Our approach looks at everything from your neck to your fingers.”

It’s an extensive search, especially if you have endured symptoms long-term without a diagnosis.

“Finding the underlying cause or causes of your symptoms can be complicated,” says Fisher. “Most people have gone months or years before being accurately diagnosed and have layered multiple dysfunctions on top of others. But, like an onion, the layers can be peeled back. And the more layers that can be removed the greater the likelihood of successful management of these symptoms.”


Diagnostic Testing


Do You Have TOS? 

Here are some tests your doctor might recommend: 

Chest X-ray
Rules out a cervical (extra) rib, which can compress blood vessels. 

Scalene Block
A local anesthetic injected into the neck’s scalene muscles. If symptoms disappear, it increases the chances you have TOS.

Electromyography/Nerve Conduction Studies
Electromyography uses an electrical recording of muscle activity to help identify the location and size of a lesion in the brachial plexus, the network of nerves that delivers signals from your spine to your hands, arms and shoulders. 

A nerve conduction study, using low-level electrical current, checks for nerve damage by evaluating and measuring how nerves deliver impulses to your body’s muscles. 

Vascular Ultrasound
A comprehensive duplex ultrasound of bilateral subclavian arteries and veins. You’re tested first in a resting position, followed by various provocative movements to look for evidence of arterial or venous compression by the thoracic outlet. The diagnostic test is performed by a technologist at an vascular laboratory accredited by the Intersocietal Accreditation Commission (IAC).  This test is relevant in diagnosis of vascular (arterial or venous) thoracic outlet syndrome (aTOS or vTOS, respectively).


Surgical Options


Veins or arteries affected by Thoracic Outlet Syndrome typically require surgery combined with blood thinners to prevent clotting and “clot-busting” medication called thrombolytics when clots form in a vein or arteries of the arm. 

“When needed,” says Dr. Parth Shah, a vascular and endovascular surgeon at the Heart & Vascular Institute, “we perform surgical decompression of the thoracic outlet, with or without a complete release of the scar tissue around the brachial plexus.”

If you require surgery, expect to spend one or two nights (nTOS) or up to five nights (for either vTOS or aTOS) in the hospital. A small drain placed during surgery is typically removed in the next day or two.

"The primary focus," says Dr. Shah, "is on pain control, usually by patient-controlled analgesia, and deep-breathing exercises (incentive spirometry). A chest X-ray is usually performed in the recovery room."

Patients are encouraged to resume full range of motion as soon as they are able. Physical therapy is a critical element of postoperative recovery, usually starting three to five weeks after surgery, depending on the recovery and pain control.

Venous TOS (vTOS)

When at least one vein under the collarbone is compressed. (Five percent of cases.) A compressed vein can cause blood clots, or Paget-Schroetter syndrome, also known as effort thrombosis.

Symptoms

  • Tingling in hand and arm, often painful.
  • Increased prominence of veins in neck, shoulder and hand.
  • Bluish hands and arms.

"These patients commonly have symptoms of intermittent arm swelling associated with prominent superficial veins, especially at the upper arm (near the shoulder) and anterior chest wall area," says Dr. Shah. 

What To Expect

  1. Acute treatment of the blood clot in the vein: Anticoagulation and thrombolysis (“clot-busting” medication) using a special catheter (EKOS) that breaks the blood clot using ultrasonic waves while significantly reducing need for the medication (Alteplase) dosage.
  2. Surgical decompression of the thoracic outlet: Removal of the first rib and adjacent scalene muscle (anterior and middle scalenectomy) using what doctors call a “paraclavicular” approach, with incisions above and below the collarbone.

Arterial TOS (aTOS)

Arterial TOS, when at least one artery under the collarbone is compressed, accounts for 1 percent of all thoracic outlet syndrome cases.

Symptoms

Blockage (embolism) of an artery in the hand or arm.

  • Tingling, numbness in fingers.
  • Cold, pale fingers or hands.
  • Wounds or ulcerations in the fingers that don’t heal properly.
  • Arm fatigue when in use.
  • Hand pain or weakness, often sudden.

What To Expect

  1. If you have acute or subacute upper-extremity ischemia – inadequate blood flow – you’ll undergo surgery to improve blood flow to the distal forearm and hand. This is usually accomplished by using the thrombolytics (“clot-busting” medication). That’s followed by anticoagulation treatment.
  2. Days to weeks later, doctors will perform a surgical decompression of your thoracic outlet using a supraclavicular (above the clavicle) incision. Occasionally, an additional, below-the-clavicle incision is needed to control the axillary artery, a major blood vessel of the upper limb.
  3. Reconstruction of the subclavian artery, which supplies blood to the arm, is also performed during the same surgery using an autologous (from another part of the body) or homologous (donor tissue) saphenous vein graft.

Neurogenic TOS (nTOS)

This syndrome, in 90 percent of cases, affects the network of nerves known as the brachial plexus that extends from the backside of the base of the neck through the armpit.

"Neurogenic thoracic outlet syndrome is an often-disputed diagnosis that has resulted in variable successful outcome rates in the literature,” says Dr. Joel Bauman, a Heart & Vascular Institute neurosurgeon. “Our thorough multidisciplinary approach affords three valuable surgical opinions about the candidacy of a patient for successful surgery. Through careful pre-operative evaluation, we believe that the best possible outcomes are assured BEFORE surgery is actually performed."

Symptoms

  • Numbness, tingling in arms or fingers.
  • Pain, weakness in shoulders or arms.
  • Pain, aches in neck, shoulder or hand.
  • Arms tire easily.
  • Tingling in fingers or arms.

What To Expect

The Heart & Vascular Institute summons the expertise of multiple specialists when caring for patients with nTOS: Our rehabilitation network and physicians from the Thoracic, Vascular and Neurosurgery and Neurology departments will work together for you.

"These patients have often been suffering from these symptoms for long duration (months to years) before the diagnosis of nTOS is made," says Dr. Shah.

This video, produced by HVI's Dr. Parth Shah, demonstrates what to expect if you require surgery for Thoracic Outlet Syndrome:


Aftercare


Pain Control, Physical Therapy

On average, you’ll spend either 1-2 nights (nTOS) or 2-5 nights (vTOS and aTOS) at the hospital after surgery. A chest X-ray is usually performed in the recovery room. A small drain placed during surgery is usually removed within two days.  

Our primary focus is pain control, usually by patient-controlled medication and deep-breathing exercises using a device called an incentive spirometer to keep your lungs healthy. 

We encourage all patients to resume full range of motion as soon as possible. Physical therapy is an important part of postoperative recovery. It usually starts between three and five weeks after surgery, depending on the recovery and pain control.

After at least three weeks of recovery, you’ll begin a physical therapy regimen to stabilize and strengthen your neck area. The protocol avoids aggressive range-of-motion neck movements and otherwise aggravating your symptoms.

Physical Therapy Timeline

Weeks 3-5 after surgery:

  • Scar massage (when healed).
  • Soft-tissue mobilization of the cervical (neck) and thoracic spine: A hands-on method to improve muscle function.
  • Pain-free nerve glides/flossing: Stretching and releasing the nerve repeatedly. The peripheral nerve, when injured, doesn’t glide naturally through its sheath, causing pain.
  • Gentle Active Range of Motion (AROM): cervical/thoracic spine and shoulder.
  • Postural education: Avoiding pain caused by poor posture.
  • Ergonomic/workstation education: Maintains proper alignment of your bones and joints, encourages good posture and decreases the likelihood that your daily movements and positioning will cause pain or aggravate symptoms.
  • Diaphragmatic breathing: The proper way to breath, avoiding overuse of accessory respiratory muscles – shoulder girdle and chest wall muscles used by people with breathing problems to enhance air flow in and out of the lungs.
  • Scapular mobilization: Strengthening shoulder girdle muscles.
  • Scapular stabilization: Stabilizing this area helps you regain normal use of your arm.
  • Gentle mobilization: cervical/thoracic spine, glenohumeral (shoulder) joint and AC (acromioclavicular) joint at the top of the shoulder.
  • If symptoms are worse at night and you have a positive Cyriax release test – numbness or other symptom after a physical therapist elevates your shoulder girdle, then releases after up to 3 minutes: Exercise the upper extremities nightly up to 30 minutes.

Weeks 6-9:

  • Continue with any of the above, if necessary.
  • More aggressive mobilization, if necessary.
  • Progress with strength/stabilization.
  • Functional retraining, especially with overhead tasks.

Meet our Thoracic Outlet Center Providers:

Name Specialties Location
Gifford, Edward D., MD, RPVI 860.522.4158
  • Vascular Surgery
  • Endovascular Surgery
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  • Hartford
  • Norwich
  • Waterford
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Katigbak, Mario Winn, MD
4.9 /5
108 surveys
860.696.4306
  • Thoracic Surgery
  • Hartford
  • Manchester
  • Norwich
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Shah, Parth S., MD, FACS
4.9 /5
58 surveys
860.223.0800
  • Vascular Surgery
  • Endovascular Surgery
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  • Plainville
  • Southington
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