Arterial TOS Treatment

All TOS experts agree that surgical treatment is a necessity for ATOS. The majority of conservative (non-surgical) treatment is done in addition to surgery either to prevent further clotting while waiting for surgery or to make surgery more easily accomplished and more successful. Occasionally, there can be certain situations in which a patient might have a medical condition or circumstance which renders surgery not an option, but in general, it is always recommended. In the case of an arterial blood clot, the clot can travel and end up in smaller arteries down lower in the arm, hand and fingers. If not treated very quickly and properly, this puts various parts of the arm and even the entire arm in danger of not having blood flow (ischemia) which is a condition that can result in loss of fingers, the hand, or the arm. Rarely, a clot can travel in the opposite direction of the blood flow and travel backwards getting into the vertebral artery which supplies the brain with blood. When this happens, it can lead to a stroke. Although exceedingly rare, in the case of an arterial aneurysm rupture, it can result in massive hemorrhage which can be life threatening if not treated emergently and properly.

CONSERVATIVE TREATMENT (NON-SURGICAL or PRE-SURGICAL)

Anticoagulation (Blood Thinners)

Almost all TOS experts agree that once a patient has been definitively diagnosed with ATOS, blood thinner medication should begin immediately. This is typically in the form of an injection or an oral medication, but sometimes it is via IV infusion depending on the circumstances. Sometimes both anticoagulants and antiplatelets are administered. The main goals of blood thinners with respect to ATOS are to:

Prevent the clot from embolizing and traveling to other arteries
Prevent further clots from forming

Blood thinners are only meant to be an interim treatment until the patient can have surgery. Because ATOS blood clots are caused by extrinsic (external) compression of the artery by the cervical or first rib and other structures, clots can still occur despite being on blood thinners.

Thrombolysis (Breaking Up/Dissolving the Clot)

Thrombolysis in the scenario of ATOS is typically only used for clots that have traveled to smaller arteries lower down in the arm. It involves inserting a needle or sheath into an artery on the affected arm. A catheter is then inserted into the artery and is slowly guided through the artery until it reaches the location of the clot. Thrombolysis can be done in a few different ways. One way is to use medication only. This involves continuous infusion of medication to dissolve the clot via the catheter that was inserted into the artery next to the clot. This is usually done over 24-48 hours and requires hospitalization to be monitored in the ICU. The other way to accomplish thrombolysis is by a combination of medication to dissolve the clot and a mechanical device on the tip of the catheter to physically break up the clot. This can usually be achieved in a matter of hours and typically does not require overnight hospitalization.

Stents

Placing stents inside vessels to help them remain open is commonplace for narrowed vessels in other parts of the body and under different circumstances. However, all TOS experts agree that stents should not be placed into the axillary-subclavian artery prior to surgery. Because the arterial narrowing in the case of ATOS is caused by external compression of the artery by the cervical or first rib and other structures, failure or fracture of the stent is almost guaranteed. If this occurs, it can lead to further clotting and pain, and can also make future surgical treatment much more difficult.

SURGICAL TREATMENT

Surgery is the mainstay of treatment for ATOS. Since, by definition, ATOS involves a clot or arterial damage/abnormality, it is the only definitive long-term treatment. If the mechanical compression that is compressing the artery is not removed, the patient risks developing further clots (even if on blood thinners) and permanently damaging the artery leading to possible life or limb threatening conditions. As with any type of TOS, the surgery is extremely complicated and takes place in a very complex area of the body where several vital structures are all packed tightly together in a very small space. In the case of ATOS in particular, it can be even more technically challenging and risky especially if artery reconstruction is required. With a surgeon who is not experienced in TOS surgery, damage to vital vessels and to nerves that serve the arm and hand can occur and can be devastating. Therefore, of the surgeons available to a patient, it is recommended to choose the surgeon who has the highest level of TOS experience possible. There are very few dedicated TOS centers in the United States and even fewer throughout the rest of the world. Because of this, many patients must travel to other states or other countries for experienced care. However, choosing a highly experienced TOS surgeon gives the patient the highest chance for a successful outcome and the lowest chance for serious complications. Under these circumstances, TOS surgery can be very safe and successful. For help finding a TOS surgeon, click here. In addition, it is important to note that not all ATOS surgery is an emergency. It is typically only an emergency in the extremely rare circumstance where an aneurysm has ruptured or if the patient has significant arm ischemia from lack of blood flow and even then, once surgical removal of the clot(s) has taken place, there is usually still time to find an experienced TOS surgeon to perform the thoracic outlet decompression surgery with possible artery repair or reconstruction. In situations where the patient only has a small aneurysm or post-stenotic dilatation, surgery can be performed on an elective basis with plenty of time to be referred to an experienced TOS surgeon, if possible.

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What does surgery for ATOS entail?

In general terms, ATOS surgery is often referred to as thoracic outlet decompression surgery as it involves removing anatomical structures and scar tissue in order to decompress the artery. ATOS surgery usually involves of hospital stay of 2-6 nights depending on what was done during surgery. The main goals of ATOS surgery are (1) to decompress the artery to prevent any further damage or blood clots, (2) to restore and maintain normal blood flow through the axillary-subclavian artery, and (3) to restore and maintain blood flow through smaller arteries lower down in the arm. There are actually several components to ATOS surgery. Depending on the patient’s findings and the surgeon’s protocol and experience level, ATOS surgery includes some or all of the following:

Removal of the first rib known as First Rib Resection (complete or partial)
Removal of cervical rib, if present, known as Cervical Rib Resection (complete or partial)
Removal of the anterior scalene muscle known as Anterior Scalenectomy (complete or partial)
Removal of the middle scalene muscle known as Middle Scalenectomy (complete or partial)
Removal of scar tissue from around the nerves known as Brachial Plexus Neurolysis (complete or partial)
Removal of scar tissue from around the artery known as Arteriolysis (complete or partial)
Intraoperative Arteriogram or Intravascular Ultrasound
Artery repair or reconstruction
Thrombolysis or Thromboembolectomy

Most TOS experts believe that, at a minimum, removing the first rib, cervical rib, and most or all of the anterior scalene, in addition to performing arteriolysis is the best way to achieve a complete and thorough decompression and to prevent recurrence of ATOS. Most TOS experts also agree that, in the case of clots, a certain size aneurysm, or certain damage to the artery, arterial repair or reconstruction is required. There are also several different surgical approaches to take, and each of them allows for different variations in treatment. Also, because TOS is not a well-known condition and surgery for it is not regularly performed by most surgeons, there exists a wide variety of surgical component combinations that can be performed for ATOS. For this reason, let’s break each component down a little further:

Removal of the first rib known as First Rib Resection (complete or partial) As far as history goes, removing the first rib is probably the oldest and most common component of TOS decompression surgery. Some surgeons believe that removal of only the cervical rib is enough for ATOS, but most TOS experts believe that, for most ATOS patients, all or part of the first rib should be removed in addition to the cervical rib. Complete removal of the entire first rib helps to decompress the nerves and both vessels of the thoracic outlet. However, when the artery is the only structure that needs decompressing, as is usually the case with ATOS, then typically only the back ¾ (approx.) of the first rib needs to be removed. This is often referred to as the posterior portion of the first rib. Essentially, cutting the rib at the point directly in front of where the anterior scalene muscle attaches to it and removing it from that point all the way back to where the rib attaches to the spine should suffice. Most TOS experts agree that removing any less of the first rib can be problematic as complete decompression of the artery might not be achieved. This is especially true in the case of an anomalous first rib. In addition to not achieving complete decompression of the artery, some TOS experts have also seen that any amount of posterior rib that is left behind can become an attachment point for post-surgical scar tissue. If scar tissue attaches to the remaining rib, it can compress the artery again and result in a return of symptoms. This scar tissue attached to the remaining rib can also compress the brachial plexus nerves resulting in post op development of secondary NTOS. Therefore, removal of the first rib can be a twofold component of ATOS surgery – (1) decompressing the artery and (2) preventing recurrence and secondary NTOS if scar tissue forms.

Removal of cervical rib, if present, known as Cervical Rib Resection (complete or partial) a cervical rib is almost always involved in axillary-subclavian artery compression. Most TOS experts will remove the cervical rib in addition to the first rib. It is usually removed in its entirety. However, certain surgical approaches can limit access to the entire cervical rib and thus partial removal might only be possible. As with the first rib, this might not achieve complete decompression, and can also be a risk to become a scar tissue attachment point which can compress the artery again and result in return of symptoms or compress the nerves leading to the development of secondary NTOS.

Removal of the anterior scalene muscle known as Anterior Scalenectomy (complete or partial) because the anterior scalene is attached to the first rib, in order to remove the first rib, it must, at a minimum, be detached from the first rib. Whether it also gets removed either partially or completely is up to the surgeon. Detaching the anterior scalene from the rib but not removing it is called anterior scalenotomy. Almost all TOS experts agree that either some or all of the anterior scalene muscle should be removed for purposes of complete decompression of the artery. In addition, some surgical approaches limit access to be able to remove the entire anterior scalene muscle. One potential issue with a partial anterior scalenectomy or anterior scalenotomy is that there is a chance for the remaining part of the scalene to reattach to other structures and cause recurrent artery compression and/or cause compression of the brachial plexus nerves resulting in development of secondary NTOS. This has been a consistent finding during reoperations on patients who had either prior partial anterior scalenectomy or anterior scalenotomy.

Removal of the middle scalene muscle known as Middle Scalenectomy (complete or partial) because the middle scalene is attached to the first rib, in order to remove the first rib, it must, at a minimum, be detached from the first rib. Whether it also gets removed either partially or completely is up to the surgeon. Detaching the middle scalene from the rib but not removing it is called a middle scalenotomy. The middle scalene can sometimes play a part in axillary-subclavian artery compression, but some TOS experts believe that it is unnecessary to remove the middle scalene at all and that simply detaching it from the first rib in order to remove the first rib is all that is needed. In addition, some surgical approaches limit access to be able to remove the entire middle scalene muscle. Other TOS experts believe that the middle scalene muscle should be removed particularly due to the fact that there is a chance for the remaining part of the scalene to reattach to other structures and cause recurrent artery compression and/or compression of the brachial plexus nerves resulting in development of secondary NTOS. This has been a consistent finding during reoperations on patients who had either prior partial middle scalenectomy or middle scalenotomy.

Removal of scar tissue from around the nerves known as Brachial Plexus Neurolysis (complete or partial) even though a patient might be primarily undergoing surgery for artery compression, it is not uncommon for these patients to also have some level of scar tissue around the brachial plexus nerves as the nerves and artery are right next to each other. Most TOS experts will go ahead and perform neurolysis if they notice scar tissue around the nerves during surgery. Some surgical approaches for ATOS allow access for a complete neurolysis of all five brachial plexus nerve roots and some only allow access for neurolysis of the lower three nerve roots. Some experts believe that leaving any scar tissue around the nerves would not constitute a full decompression and could therefore continue to cause symptoms.

Removal of scar tissue from around the artery known as Arteriolysis (complete or partial) almost all TOS experts agree that arteriolysis of the artery should be done for complete decompression. However, some experts believe that certain surgical approaches allow for a more complete external arteriolysis than others, and removal of all scar tissue from around the artery is critical to achieving complete decompression especially if no artery reconstruction is needed.

NOTE: Most TOS experts agree that some type of artery repair or reconstruction is required if the dilated section of the artery is more than twice the size of the artery’s normal size, if there are clots that have traveled to smaller arteries lower down in the arm, or if there is excessive damage or certain abnormalities within the artery. There are various options for repair and reconstruction of the artery. Below are descriptions of the components of ATOS surgery related to this issue.

Intraoperative Arteriogram or Intravascular Ultrasound some, but not all TOS experts, perform an arteriogram during surgery. Some will use it following the decompression part of surgery to determine whether the axillary-subclavian artery has internal damage or abnormalities that would warrant artery repair or reconstruction. Intravascular ultrasound can also be used for this purpose. Arteriogram can also be done to assess for clots in the smaller arteries lower down in the arm to determine whether thrombolysis or thromboembolectomy is necessary to restore blood flow to those arteries. Arteriogram can also be done at the end of surgery to determine whether any thrombolysis or thromboembolectomy was successful in restoring blood flow to the smaller arteries.

Artery Repair or Reconstruction most TOS experts agree that if the artery is too damaged or has severe wall abnormalities, then repair or reconstruction of the artery is required. Only certain surgical approaches allow for artery reconstruction. Depending on the surgeon’s knowledge and familiarity with performing specific aspects of TOS surgery with a certain surgical approach, more than one surgical approach might be used for ATOS surgery with reconstruction. There are several different options for artery repair and reconstruction. Which option is used can depend on the type of arterial damage, how much of the artery is damaged, and the location of the damaged area. The most common options are:

Primary Repair – the damaged section of the artery is removed and the two remaining ends of the artery are sewn together
Bypass Graft – removing the damaged section of the artery and replacing it with donor or synthetic material

Most experts will perform decompression and reconstruction in the same surgery. However, if repairing or reconstructing the artery was not addressed during the original decompression surgery, it can be done later in a separate surgery.

Thrombolysis or Thromboembolectomy if clots in the smaller arteries lower down in the arm (distal arteries) were not addressed separately prior to decompression and reconstruction surgery, they can be addressed during it. This can be done with thrombolysis, by surgically removing the clots, or by a combination of both. In some cases, if the clots in these arteries are old and scarred and have caused damage to the artery, bypass reconstruction might be required to restore blood flow.

As with any surgery, the decision to have surgery and which components should be included in said surgery should be made based on advice given by the patient’s surgeon as to what is best for their specific clinical situation.

ATOS Surgery Recovery

In general, the post-hospital recovery for ATOS surgery is usually fairly straightforward. Of course, this can depend on what exactly was done during surgery and what complications occurred. Below is a list of expectations following ATOS surgery keeping in mind that every recovery is different and not everyone will experience the things listed.

Can include continuing to experience pre-op symptoms such as arm/hand numbness, tingling, color changes, temperature changes or pain
new symptoms can be felt in the neck, chest, upper back, shoulder, arm, or hand
because nerves usually have to be manipulated during surgery and some patients also require brachial plexus neurolysis, some experience nerve symptoms from surgery such as numbness, tingling, pain, burning, skin hypersensitivity, itching, stinging, electrical zaps, cold sensations, hot sensations, skin color and temperature changes, muscle twitching, neck and upper back muscle tightness
nerve symptoms are usually very temporary only lasting a few weeks depending on how involved the nerves were in the compression and how much scar tissue was removed
Some loss of arm strength and range of motion. Although, some can have full range of motion immediately after surgery, most have some degree of diminished strength and range of motion
Low energy and general fatigue with activity. For some, this can last for a few months.
Remaining on blood thinners for anywhere from 6 weeks to 6 months after surgery or sometimes longer depending on the circumstances and post-surgical course
Most do PT to regain arm strength and range of motion
Most are fully healed after 3-6 months

Restrictions

Most return to work anywhere from 4-12 weeks post op depending on how physically demanding the job is
Most have weight restrictions of no more than 5-10 lbs for at least 4-12 weeks. This usually includes lifting, pushing, pulling, etc.
Most have activity restrictions including no overhead or above shoulder activity and nothing repetitive for at least 4-12 weeks
Most are able to return to driving by 4 weeks post op
Restrictions are at the discretion of the surgeon as to when they are imposed and when they are lifted.

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Return of Symptoms (Recurrent ATOS)

Sometimes a patient will experience initial relief and then have symptoms return. The two most likely causes for a recurrence of ATOS symptoms are:

Complete decompression not achieved during surgery this would occur as described earlier on this page when some anatomy, usually rib or scalene muscle, was either not removed at all or only partially removed.

No, reoccluded or failed Artery Repair or Reconstruction this would occur when a patient whose artery is damaged or seriously abnormal did not have artery repair or reconstruction performed, had unsuccessful artery repair or reconstruction, or had artery repair or reconstruction which reoccluded.

Secondary NTOS

Sometimes a patient who has ATOS which was successfully treated with surgery will begin to experience symptoms of NTOS sometime after surgery. As described earlier on this page, this can occur when the first rib is not removed, when too much of the posterior portion of the rib is left in, when too much of the cervical rib is left in, or when there is incomplete anterior and/or middle scalenectomy.

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Arterial TOS Treatment