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Eur J Cardiothorac Surg 2007;31:753-754. doi:10.1016/j.ejcts.2007.01.004
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Reply to Sanders

^a Department of Cardiothoracic Surgery, University Medical Center Groningen, The Netherlands
^b Department of Internal Medicine, University Medical Center Groningen, The Netherlands

Received 2 January 2007; accepted 4 January 2007.

^_* Corresponding author. Address: Thorax Centre, Room T4.234, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands. Tel.: +31 50 3613238; fax: +31 50 3611347. (Email: t.ebels{at}thorax.umcg.nl).

Key Words: Thoracic outlet syndrome • Vascular thoracic outlet syndrome • Neurogenic thoracic outlet syndrome

We thank Dr Sanders sincerely for his scholarly opinion [1]. His extensive knowledge about thoracic outlet syndrome (TOS) is well respected.

TOS is a much disputed pathophysiologic entity. As made clear by Dr Sanders, the definition of TOS varies between physicians, hospitals and countries, and this contributes to the controversy associated with this subject. Whatever the confusion regarding the definition of this syndrome, our selection for surgery resulted in a quite acceptable success rate of 82.1% of patients undergoing a transaxillary first rib resection [2]. Therefore, we conclude that the patient selection we used is worthwhile in respect to outcome.

The critique Dr Sanders has about our usage of the term ‘vascular TOS’ is essentially correct. With vascular TOS as we have used it, venous compression is not included. However, in our clinic venous compression is very rarely seen, and it presents with a very different set of symptoms. Probably ‘arterial TOS’ describes better our selection criterion. Dr Sanders speaks of arterial TOS as a result of emboli from subclavian artery thrombosis, a syndrome we very rarely encounter with predominantly attitude-dependent symptoms and not those of a (unilateral) Raynaud's phenomenon. Our definition of clinically demonstrated attitudinal compression coinciding with attitude-dependent incapacitating symptoms is based entirely on functional grounds. This difference in definition will probably result in a difference in patient selection and thus patient groups might be more difficult to compare.

The suggestion that our group consisted mainly of patients with neurogenic compression cannot be excluded, because there is no objective test to confirm or deny this. As the brachial plexus and the subclavian artery course in adjacent positions through the scalenus gate, joined compression seems likely. Perhaps positive photoelectrical pletysmography (PPG), therefore, can be regarded as a surrogate variable for neurogenic compression.

We are well aware of the incidence of arterial compression in healthy volunteers [3–5]. In these specific studies, arterial pulsation was assessed during provocative manoeuvres, but no attention was given to symptoms of compression coinciding with these manoeuvres. We believe that a positive PPG result coinciding with incapacitating symptoms during multiple provocative manoeuvres or positions is enough evidence for compression of the subclavian artery and the brachial plexus to offer the patient a transaxillary first rib resection. Our success rate supports this thought. Compression of (part of) the brachial plexus will most likely be responsible for some of the symptoms in our patient group that we have defined as ‘vascular’. There is no objective test, however, to establish unequivocally brachial plexus compression. Considering our suggestions that symptoms could shift from vascular to neurogenic after first rib resection, we presume that with arterial compression, brachial plexus compression can be present as well.

References

1. Sanders RJ. Vascular thoracic outlet syndrome. Eur J Cardiothorac Surg 2007;31:753.[Free Full Text]
2. Geven LI, Smit AJ, Ebels T. Vascular thoracic outlet syndrome. Long posterior rib stump causes poor outcome. Eur J Cardiothorac Surg 2006;30:232-236.[Abstract/Free Full Text]
3. Gergoudis R, Barnes RW. Thoracic Outlet arterial compression; prevalence in normal persons. Angiology 1980;31:538-541.[Abstract/Free Full Text]
4. Warrens A, Heaton JM. Thoracic Outlet compression syndrome: the lack of reliability of its clinical assessment. Ann R Coll Surg Engl 1987;69:203-204.[Medline]
5. Sanders RJ, Haug CE. Thoracic Outlet syndrome: a common sequela of neck injuries. Philadelphia: Lippincott; 1991pp. 79–80.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tjark Ebels Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Geven, L. I. Articles by Ebels, T. Search for Related Content PubMed Articles by Geven, L. I. Articles by Ebels, T. Related Collections Peripheral vascular