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Background: The clinical outcomes of reoperations for recurrent neurogenic thoracic outlet syndrome (NTOS) remain undefined. Methods: From 2009 to 2019, 90 patients with recurrent NTOS underwent anatomically complete supraclavicular reoperation after previous operation(s) performed at other institutions using either supraclavicular (Prev-SC = 48), transaxillary (Prev-TA = 31), or multiple/combination (Prev-MC = 11) approaches. Prospectively maintained data were analyzed retrospectively. Results: The mean patient age was 39.9 ± 1.4 years, 72% were female, and the mean interval after previous operation was 4.1 ± 0.6 years. The mean Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 62 ± 2, reflecting substantial preoperative disability. Residual scalene muscle was present in 100% Prev-TA, 79% Prev-SC, and 55% Prev-MC ( P < .05). Retained/residual first rib was present in 90% Prev-TA, 75% Prev-SC, and 55% Prev-MC ( P < .05). There were no differences in operative time (overall 210 ± 5 minutes), length of hospital stay (4.7 ± 0.2 days), or 30-day readmissions (7%). During follow-up of 5.6 ± 0.3 years, the improvement in QuickDASH scores was 21 ± 2 (36% ± 3%) ( P < .01) and patient-rated outcomes were excellent in 10%, good in 36%, fair in 43%, and poor in 11%. Conclusions: Anatomically complete decompression for recurrent NTOS can be safely and effectively accomplished by supraclavicular reoperation, regardless of the type of previous operation. Residual scalene muscle and retained/residual first rib are more frequently encountered after transaxillary operations than after supraclavicular or multiple/combined operations. Supraclavicular reoperation can achieve significant symptom reduction and functional improvement for approximately 90% of patients with recurrent NTOS.

BACKGROUND: Duplex ultrasound (DU) is used in the diagnosis of neurogenic thoracic outlet syndrome (NTOS) to measure compression of the subclavian artery (SCA) which is thought to strengthen the NTOS diagnosis. However, the value of DU in NTOS remains unclear.METHODS: A retrospective review of a prospectively acquired database from the TOS center of the Catharina Hospital Eindhoven was performed of patients referred between January 2017 and December 2019. Only "proven NTOS" patients, defined as a successful response to thoracic outlet decompression (TOD) surgery based on patient-reported outcomes (NRS pain scale, CBSQ and DASH score) were included to exclude wrongfully diagnosed NTOS patient. The presence of vascular symptoms (defined as discoloration, edema or temperature changes of the hand or fingers), results of provocative maneuvers, and outcome of DU was used for analysis. To assess the link between vascular symptoms and compression on DU, a chi-squared test was performed. Further, we looked for a correlation between vascular symptoms, compression on DU and clinical outcome using a repeated measures analysis of variance (ANOVA).RESULTS: Vascular symptoms were seen in 49 of 133 patients (36.8%). In total, 51 of 133 patients (38.3%) had at least 50% variation in SCA peak systolic velocity (PSV) during DU at the level of SCA stenosis. SCA occlusion was seen in 11 patients (8.3%) during provocative maneuvers. The presence of clinical "arterial symptoms" was not significantly correlated with vascular laboratory findings, neither for alterations in PSV during DU (P = 0.245) nor for positional SCA occlusion (P = 0.540). No statistically significant correlations between the degree of SCA stenosis and postoperative outcomes, as measured with the DASH, CBSQ, or NRS scale for pain were found (P = 0.787).CONCLUSIONS: The role of DU in the work-up of NTOS in patients with vascular complaints is questionable. Changes in flow velocities are seen in NTOS patients and do not correlate with "vascular symptoms" or clinical outcome.

Allergic diseases are a global health challenge. Individuals harboring loss-of-function variants in transforming growth factor–β receptor (TGFβR) genes have an increased prevalence of allergic disorders, including eosinophilic esophagitis. Allergic diseases typically localize to mucosal barriers, implicating epithelial dysfunction as a cardinal feature of allergic disease. Here, we describe an essential role for TGFβ in the control of tissue-specific immune homeostasis that provides mechanistic insight into these clinical associations. Mice expressing a TGFβR1 loss-of-function variant identified in atopic patients spontaneously develop disease that clinically, immunologically, histologically, and transcriptionally recapitulates eosinophilic esophagitis. In vivo and in vitro, TGFβR1 variant–expressing epithelial cells are hyperproliferative, fail to differentiate properly, and overexpress innate proinflammatory mediators, which persist in the absence of lymphocytes or external allergens. Together, our results support the concept that TGFβ plays a fundamental, nonredundant, epithelial cell–intrinsic role in controlling tissue-specific allergic inflammation that is independent of its role in adaptive immunity.

To assess clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS).A retrospective single-center review was conducted for 266 patients that underwent primary surgical treatment for VTOS between 2016 and 2022. Clinical outcomes were compared between patients in four treatment groups based on intraoperative venography.There were 132 men and 134 women with a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range 12-66). Timing of clinical presentation was acute in 132 (15 days, 50%), subacute in 71 (15-90 days, 27%), and chronic in 63 (90 days, 24%). Venography with catheter-directed thrombolysis/thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 (71%) and the median interval between symptoms and surgery was 78 days. Following paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%), but 26 (10%) had a long chronic AxSCV occlusion with insufficient axillary vein inflow for bypass reconstruction. Patch angioplasty was performed for a focal AxSCV stenosis in 55 (21%) and bypass graft reconstruction for a segmental AxSCV occlusion in 35 (13%). Patients undergoing external venolysis alone (patent or occluded AxSCV, n = 176) had lower mean operative time, postoperative length of stay, reoperations, and late reinterventions than those undergoing AxSCV reconstruction (patch or bypass, n = 90), with no differences in overall complications or 30-day readmissions. At median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling and only 17 (6%) were on anticoagulation treatment, with 95% of those having a patent AxSCV at the end of surgery being free of arm swelling versus 69% of those left with a long chronic AxSCV occlusion (P.001). Patients having CDT at initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery than those without CDT (30% vs. 44%, P = .034) and 60% less likely to have arm swelling at follow-up (5% vs. 13%, P.05).Paraclavicular decompression, external venolysis, and selective AxSCV reconstruction based on intraoperative venography can provide successful and durable treatment for90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt utilization of CDT, and even more effective surgical treatment.

The objective of this retrospective analysis of prospectively collected data was to assess the test-retest reliability and validity of the elevated arm stress test (EAST) as measured by the duration in a cohort of patients with suspected neurogenic thoracic outlet syndrome (NTOS).Patients evaluated for NTOS between January 2017 and September 2018 were identified. Test-retest reliability by the intraclass correlation coefficient was determined for duration of the EAST. For the validity analysis, patients were classified in a proven NTOS group or a symptomatic control group without NTOS using the Society for Vascular Surgery reporting standards and the outcome of thoracic outlet decompression surgery. A receiver operating characteristic curve was made for the duration of EAST. The area under the curve, and positive and negative predictive values were calculated for the EAST.In total, 428 patients with suspected NTOS were retrospectively analyzed. Of these patients, 61 were excluded because no EAST data was available. Another 101 patients were excluded because of inconclusive reporting standards, arterial or venous TOS, or because thoracic outlet decompression surgery was not performed or had a negative result. The validity analysis in the remaining 266 patients showed an area under the curve for the duration of the EAST of 0.62 (95% confidence interval, 0.55-0.69). The positive predictive value of the duration ranged between 65% and 66%, and the negative predictive value between 53% and 58%. For the test-retest reliability analysis, 118 patients were excluded because they performed only one measurement in a 100-day time period. Analysis in the remaining 148 patients showed an intraclass correlation coefficient value of 0.65 (95% confidence interval, 0.55-0.74) for duration.The EAST measured by the duration showed a moderate test-retest reliability, but the discriminative value was low in the diagnosis of NTOS. The outcome of the EAST measured by the duration should be used with caution.

Venous thoracic outlet syndrome (TOS) is uncommon but occurs in young, healthy patients, typically presenting as subclavian vein (SCV) effort thrombosis. Venous TOS arises through chronic repetitive compression injury of the SCV in the costoclavicular space with progressive venous scarring, focal stenosis, and eventual thrombosis. Diagnosis is evident on clinical presentation with sudden spontaneous upper extremity swelling and cyanotic discoloration. Initial treatment includes anticoagulation, venography, and pharmacomechanical thrombolysis. Surgical management using paraclavicular decompression can result in relief from arm swelling, freedom from long-term anticoagulation, and a return to unrestricted upper extremity activity in more than 90% of patients.

Mycobacterium tuberculosis (Mtb) infection induces pulmonary expression of the heme-degrading enzyme heme oxygenase-1 (HO-1). We have previously shown that pharmacological inhibition of HO-1 activity in experimental tuberculosis results in decreased bacterial loads and unexpectedly that this outcome depends on the presence of T lymphocytes. Here, we extend these findings by demonstrating that IFNγ production by T lymphocytes and NOS2 expression underlie this T-cell requirement and that HO-1 inhibition potentiates IFNγ-induced NOS2-dependent control of Mtb by macrophages in vitro. Among the products of heme degradation by HO-1 (biliverdin, carbon monoxide, and iron), only iron supplementation reverted the HO-1 inhibition-induced enhancement of bacterial control and this reversal was associated with decreased NOS2 expression and NO production. In addition, we found that HO-1 inhibition results in decreased labile iron levels in Mtb-infected macrophages in vitro and diminished iron accumulation in Mtb-infected lungs in vivo. Together these results suggest that the T-lymphocyte dependence of the therapeutic outcome of HO-1 inhibition on Mtb infection reflects the role of the enzyme in generating iron that suppresses T-cell-mediated IFNγ/NOS2-dependent bacterial control. In broader terms, our findings highlight the importance of the crosstalk between iron metabolism and adaptive immunity in determining the outcome of infection.

PURPOSE OF REVIEW: Neurovascular compression in the upper extremity is rare but can affect even those participating in high-level competitive athletics. To assess optimal approaches to treatment, in this review, we evaluate the current literature on neurovascular compressive syndromes affecting the upper extremity, with a special focus on the thoracic outlet syndrome (TOS). RECENT FINDINGS: Neurovascular compression at the thoracic outlet can involve the brachial plexus, subclavian artery, or subclavian vein, each with distinct clinical manifestations. Neurogenic TOS is best treated with surgical decompression, if physical therapy has not improved symptoms. Venous TOS results in acute thrombosis superimposed on chronic venous compression. Treatment is best directed at early anticoagulation, catheter-directed thrombolysis, and surgical decompression, with most patients able to discontinue anticoagulation and return to high-level athletic activity. Arterial TOS is related to aneurysmal degeneration of the subclavian artery with distal embolization, leading to limb-threatening ischemia. This should be aggressively treated with surgery. Similar degenerative changes can occur in the axillary artery and its branches, leading to distal embolization. Prompt recognition of these potential sources of limb-threatening ischemia is critical to limb preservation. SUMMARY: TOS includes rare but important conditions in the overhead athlete. Recent advances in physical therapy and image-guided diagnostic techniques have facilitated more accurate diagnosis. Surgical treatment remains the gold standard to maximize function or for limb preservation, and future research is needed to clarify optimal pain and physiotherapy regimens, as well as to examine novel approaches to neurovascular decompression.

Objective To assess the utilization and consequences of upper extremity Duplex ultrasound in the initial diagnostic evaluation of patients with suspected subclavian vein (SCV) thrombosis and venous thoracic outlet syndrome (VTOS). Methods A retrospective single-center review was conducted for patients that underwent primary surgical treatment for VTOS between 2008 and 2017, in whom an upper extremity ultrasound had been performed as the initial diagnostic test (n = 214). Clinical and treatment characteristics were compared between patients with positive and false-negative ultrasound studies. Results There were 122 men (57%) and 92 women (43%) that had presented with spontaneous idiopathic arm swelling, including 28 (13%) with proven pulmonary embolism, at a mean age of 30.7 ± 0.8 years (range 14-69). Upper extremity ultrasound had been performed 23.8 ± 12.2 days after the onset of symptoms, with confirmation of axillary-SCV thrombosis in 169 patients (79%) and negative results in 45 (21%). Of the false-negative ultrasound study reports, only 8 (18%) acknowledged limitations in visualizing the central SCV. Definitive diagnostic imaging (DDI) had been obtained by upper extremity venography in 175 (82%), computed tomography angiography in 24 (11%), and magnetic resonance angiography in 15 (7%), with 142 (66%) undergoing catheter-directed axillary-SCV thrombolysis. The mean interval between initial ultrasound and DDI was 48.9 ± 14.2 days with no significant difference between groups, but patients with a positive ultrasound were more likely to have DDI within 48 hours than those with a false-negative ultrasound (44% vs 24%; P = .02). At the time of surgical treatment, the SCV was widely patent following paraclavicular decompression and external venolysis alone in 74 patients (35%). Patch angioplasty was performed for focal SCV stenosis in 76 (36%) and bypass graft reconstruction for long-segment axillary-SCV occlusion in 63 (29%). Patients with false-negative initial ultrasound studies were significantly more likely to require SCV bypass reconstruction than those with a positive ultrasound (44% vs 25%; P = .02). Conclusions Duplex ultrasound has significant limitations in the initial evaluation of patients with suspected SCV thrombosis, with false-negative results in 21% of patients with proven VTOS. This is rarely acknowledged in ultrasound reports, but false-negative ultrasound studies have the potential to delay definitive imaging, thrombolysis, and further treatment for VTOS. Initial false-negative ultrasound results are associated with progressive thrombus extension and a more frequent need for SCV bypass reconstruction at the time of surgical treatment.

Supraclavicular operations can be associated with postoperative cutaneous dysesthesia and hypersensitivity. Regenerative peripheral nerve interfaces, created by attaching the proximal end of a divided peripheral nerve into a viable muscle target, can promote neurite regrowth and neuromuscular connections to help suppress painful nerve hyperactivity. During 40 consecutive operations for neurogenic thoracic outlet syndrome, we demonstrated that division of at least one of the superficial supraclavicular cutaneous sensory nerve branches was necessary in 98% of cases. We subsequently developed a novel regenerative peripheral nerve interface for supraclavicular operations using the adjacent omohyoid muscle and have described the technical steps involved in this procedure.

Objective: We developed a standardized elevated arm stress test (sEAST) meter to standardize patients' posture and measure additional grip and fatigue parameters. In the present prospective cohort study, we aimed to determine the reliability and validity of the sEAST in the diagnosis of neurogenic thoracic outlet syndrome (NTOS).Methods: Patients evaluated for NTOS between October 2018 and February 2020 were included and performed the sEAST. The patients were classified into a proven NTOS group or a symptomatic control group using the reporting standards for NTOS and the outcome of thoracic outlet decompression surgery. Healthy persons were recruited as an asymptomatic control group. The testeretest reliability, area under the receiver operating characteristic curve, and positive and negative predictive values were calculated for each sEAST parameter.Results: A total of 426 patients with suspected NTOS and 147 healthy controls had performed the sEAST. The validity analysis was performed with data from 111 patients with proven NTOS, 94 symptomatic controls, and 147 asymptomatic controls. The reporting standards were inconclusive for 116 patients; 77 patients had been excluded because thoracic outlet decompression surgery had not been performed or was unsuccessful, and 28 because they had arterial or venous thoracic outlet syndrome. The area under the receiver operating characteristic curve for the proven NTOS group compared with the asymptomatic control and symptomatic control groups ranged from 0.59 to 0.77 and 0.54 to 0.63, respectively. The positive predictive value ranged from 46% to 65% and the negative predictive value from 51% to 66%. The testeretest reliability analysis for 80 patients with multiple sEAST measurements showed moderate to good (0.52-0.87) intraclass correlation coefficient values for the duration and grip strength parameters. However, the grip fatigue parameters demonstrated poor (0.46-0.16) intraclass correlation coefficient values.Conclusions: The sEAST showed good testeretest reliability for the duration and grip strength parameters. However, the discriminative value of all sEAST parameters was low for NTOS diagnostics. The good testeretest reliability of the sEAST parameters indicates that they could be valuable outcome measures for comparison in a diagnostic care pathway.

Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge.To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS.From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively.The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P.01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P.01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P.01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%.Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.

There continues to be a major need for more effective inflammatory bowel disease (IBD) therapies. IL-13Rα2 is a decoy receptor that binds the cytokine IL-13 with high affinity and diminishes its STAT6-mediated effector functions. Previously, we found that IL-13Rα2 was necessary for IBD in mice deficient in the anti-inflammatory cytokine IL-10. Here, we tested for the first time a therapeutic antibody specifically targeting IL-13Rα2. We also used the antibody and Il13ra2−/− mice to dissect the role of IL-13Rα2 in IBD pathogenesis and recovery. Il13ra2−/− mice were modestly protected from induction of dextran sodium sulfate (DSS)-induced colitis. Following a seven-day recovery period, Il13ra2−/− mice or wild-type mice administered the IL-13Rα2-neutralizing antibody had significantly improved colon health compared to control mice. Neutralizing IL-13Rα2 to increase IL-13 bioavailability promoted resolution of IBD even if neutralization occurred only during recovery. To link our observations in mice to a large human cohort, we conducted a phenome-wide association study of a more active variant of IL-13 (R130Q) that has reduced affinity for IL-13Rα2. Human subjects carrying R130Q reported a lower risk for Crohn’s disease. Our findings endorse moving anti-IL-13Rα2 into preclinical drug development with the goal of accelerating recovery and maintaining remission in Crohn’s disease patients.

Thoracic outlet syndrome (TOS) encompasses a group of disorders caused by compression of the neurovascular structures serving the upper extremity, resulting in three distinct conditions (neurogenic, venous, and arterial). Successful surgical treatment for all types of TOS depends on sound understanding of the relationships between the musculoskeletal and neurovascular structures in this region, as well as the variable anatomy and pathologic findings likely to be encountered. The principal risks of thoracic outlet decompression revolve around the potential for nerve or vascular injury in this area, as well as operative inadequacies that may lead to persistent or recurrent problems. In current practice, the frequency of complications associated with thoracic outlet decompression are very low in the hands of experienced surgeons, but there remains potential for significant injury to the brachial plexus, phrenic nerve, long thoracic nerve, subclavian artery, and subclavian vein. Other potential concerns include postoperative pneumothorax, pleural effusion, wound hematoma and hemothorax, and persistent lymph leak and chylothorax. The frequency of persistent or recurrent symptoms of brachial plexus compression is one of the most challenging aspects of surgical treatment for neurogenic TOS, and late complications of treatment for venous TOS may include residual subclavian vein obstruction despite adequate decompression.

Objective The purpose of this study was to determine if single injection erector spinae plane blocks are associated with improved pain control, opioid use, numbness, length of stay, or patient satisfaction compared to intraoperatively placed continuous perineural infusion of local anesthetic after decompression of neurogenic thoracic outlet syndrome. Methods This is a retrospective cohort study at a tertiary academic center of eighty patients that underwent supraclavicular decompression for thoracic outlet syndrome between May 2019 and January 2020. Forty consecutive patients treated with single-injection preoperative erector spinae plane blocks were retrospectively compared to 40 age- and gender-matched controls treated with continuous perineural infusion. Results The primary outcome of mean pain scores was not significantly different between the erector spinae and perineural infusion groups over the three-day study period (4.2-5.3 vs 3.0-5.1 P=0.08). On post-operative day 0, mean pain scores were significantly higher in the erector spinae group (4.2 vs 3.0, P=0.02). While statistically significant, the score was still lower in the erector spinae group on day 0 than on day 1,2, or 3 in either group. Opioid use, nausea, length of stay and patient satisfaction were also similar. Upper extremity numbness was significantly less severe in the erector spinae group (36% vs 73% moderate-extreme, P=0.03) at 6-month follow-up. Conclusions Seventy-two-hour perineural local anesthetic infusion did not provide superior analgesia compared to preoperative single-injection erector spinae blocks. Furthermore, there was significantly less long-term postoperative numbness associated with erector spinae blocks compared to perineural local anesthetic infusion.

Purpose of review: Thoracic Outlet Syndrome (TOS) is a spectrum of neurovascular compression affecting the upper extremity. Recent findings: The structures in the thoracic outlet involved in this compression are the brachial plexus, the subclavian artery, and the subclavian vein. Each of these structures has its own symptom complex. Neurogenic TOS is best treated with physical therapy, with subsequent surgical decompression if there are continued symptoms. Women were reported to have neurogenic TOS more frequently than men in several large series but tend to have a good response to decompression. Venous TOS is an acute-on-chronic process, where chronic injury to the subclavian vein results in acute thrombosis. Treatment involves a staged approach of thrombolysis followed by surgical decompression, allowing for a high rate of success and removing the need for long-term anticoagulation. Arterial TOS is defined by pathologic injury to the subclavian artery due to underlying bony anomalies such as cervical rib or anomalous first rib, which results in distal thrombo-emboli and potential limb-threatening ischemia. Treatment involves surgical decompression with varying types of revascularization depending on the patient presentation. Summary: Decompression of the thoracic outlet is central to the management of all forms of TOS. Women tended to make up a larger percent of the neurogenic case series, with equivalent functional outcomes to men. There was no consistent difference in rates for arterial TOS based on sex, with variable rates of reported prevalence in venous TOS, and the treatment algorithms for both are the same.

Following venography, thrombolysis and anticoagulation, comprehensive management of subclavian vein effort thrombosis due to venous TOS revolves around surgical treatment. Surgical treatment, in turn, involves first rib resection and various approaches to achieve a patent subclavian vein. The paraclavicular approach is one of several different strategies for thoracic outlet decompression, combining the advantages of supraclavicular and infraclavicular exposures, including complete resection of the first rib and direct reconstruction of the subclavian vein when needed. In this chapter we provide a detailed description of paraaclavicular decompression as a thorough, flexible, and safe approach to venous TOS. Special circumstances, potential complications and the reported results of treatment are briefly reviewed. This shows that following treatment with the paraclavicular approach, more than 90% of patients with venous TOS will have a patent subclavian vein, no arm swelling symptoms, normal function and no need for anticoagulation. We therefore believe that with expertise and experience, operative procedures based on paraclavicular exposure provide the most versatile, comprehensive, safe and successful approach to the treatment of venous TOS.

Surgical interruption of the cervical-thoracic sympathetic chain has been used for a spectrum of different purposes, but is now considered relatively rare. The current indications for cervical-thoracic sympathectomy include sympathetic-mediated skin hypersensitivity and allodynia related to complex regional pain syndrome (CRPS), and secondary vasoconstrictive upper extremity ischemia (Raynaud’s phenomenon), both of which may occur in patients with thoracic outlet syndrome (TOS). While supraclavicular, transaxillary and open transthoracic approaches to sympathectomy exist, the vast majority of interventions on the upper thoracic sympathetic trunk are now performed in a minimally-invasive fashion through video-assisted thoracoscopic surgery (VATS). The purpose of this chapter is to outline a step-wise description of video-thoracoscopic cervico-thoracic sympathectomy as applied to patients with TOS, describing a thorough, flexible, and safe approach. Video-thoracoscopic sympathectomy offers the experienced surgeon a versatile and effective strategy to intervene in well-selected patients with CRPS or digital ischemia in association with TOS.

In addition to the supraclavicular scalene triangle, brachial plexus compression in neurogenic thoracic outlet syndrome (TOS) may occur underneath the pectoralis minor muscle tendon at the level of the infraclavicular subcoracoid space. Nerve compression in the subcoracoid space can make a substantial contribution to symptoms in neurogenic TOS and untreated pectoralis minor compression may be an important factor in persistent or recurrent symptoms following operations for neurogenic TOS. Patients with neurogenic TOS may also have brachial plexus compression solely at the level of the pectoralis minor muscle, which can result in atypical chest pain. In patients properly selected based on physical examination, inclusion of pectoralis minor tenotomy provides a minimally-invasive surgical adjunct associated with low risk and a high likelihood of clinical success. Recognition and treatment of pectoralis minor syndrome has therefore become of increasing importance in the management of patients with neurogenic TOS.

Supraclavicular exposure for the surgical treatment of patients with neurogenic thoracic outlet syndrome (TOS) allows the surgeon to perform complete anterior and middle scalenectomy, complete brachial plexus neurolysis, and first rib resection, as well as pectoralis minor tenotomy, within a readily visualized operative field. A step-wise description of supraclavicular decompression is outlined in this chapter, based on sequential visualization of six “critical views” and a thorough, flexible, and safe approach. Potential complications and the reported results of treatment are briefly reviewed, indicating that >85–90% of patients with neurogenic TOS can expect substantial improvement in symptoms and function following supraclavicular decompression, with long-term recurrence rates less than 5% during follow-up. With expertise and experience, supraclavicular decompression offers the surgeon an excellent, versatile and safe approach in patients with neurogenic TOS and it has the flexibility to be applicable to all other forms of TOS and intraoperative contingencies.

Thoracic outlet syndrome (TOS) is a rare and complex group of disorders that may cause severe and disabling symptoms, and caring for patients with these conditions provides many challenges to health care providers. An organized, systematic, approach to the diagnosis and treatment of neurogenic TOS provides an opportunity for specialists to deliver patient-centered care to achieve optimal treatment results. This unique type of care is best delivered through the efforts of a multi-disciplinary team consisting of various specialists. In this chapter we focus on the care path for managing patients with a diagnosis of neurogenic TOS, as based on our experience at Washington University/Barnes-Jewish Hospital in St. Louis.

Patients that have undergone treatment for venous TOS generally have excellent clinical outcomes, but a proportion of individuals may present with persistent, progressive, or recurrent upper extremity symptoms. The purpose of this chapter is to outline the spectrum of conditions that should be considered in evaluation of such patients and a systematic approach to classify and address these problems. It can be expected that with comprehensive evaluation and appropriate treatment, the majority of patients with persistent or recurrent venous TOS can experience decreased symptoms and restoration of normal upper extremity function. Evaluation of the deficiencies found during reoperations for venous TOS is informative with regard to the optimal approaches to be taken during primary operation for this condition.

In this point/counterpoint chapter, we present the view that supraclavicular decompression is the best approach for the surgical treatment of neurogenic thoracic outlet syndrome (TOS). This is based on consideration of the limitations and deficiencies of transaxillary first rib resection, as well as the advantages of supraclavicular decompression. Potential complications are discussed along with the results of treatment. We conclude that in the hands of surgeons with experience and expertise, supraclavicular decompression offers the most thorough, versatile and safe approach to the treatment of neurogenic TOS, and it has the flexibility to be applicable to all other forms of TOS and intraoperative contingencies.

Unilateral digital ischemia is one of the most common presenting problems in patients with arterial TOS, leading to numbness, tingling, cold and painful sensations, cyanotic or pale discoloration, delayed capillary refill in the fingers, and non-healing fingertip ulceration. Diagnostic evaluation requires differentiation between proximal and distal arterial sources of thromboembolism, localized digital artery occlusion, and primary vasospasm (Raynaud’s disease). Digital emboli typically accompany arterial TOS as a result of mural thrombus formed within an area of aneurysmal degeneration in the subclavian (or axillary) arteries. While there are a variety of medical treatments to help reduce local symptoms of digital ischemia and vasospasm, definitive management depends on surgical control of the proximal source of thromboembolism. Additional interventions, such as thromboembolectomy, intra-arterial infusion of thrombolytic agents and/or vasodilators, cervical sympathectomy or periarterial digital sympathectomy, and injections of botulinum toxin to the hand, are all valuable adjuncts toward achieving optimal outcomes.

Major neurovascular conditions of the upper extremity are relatively rare and often difficult to recognize in competitive overhead athletes and those involved in frequent throwing or weight lifting regimens. Understanding these conditions is particularly important for vascular and thoracic surgeons caring for athletes, as well as orthopedic surgeons, emergency room physicians, and sports medicine specialists, because they can seriously limit athletic performance and may even have limb-threatening consequences. Some of the most significant upper extremity neurovascular disorders are related to compression of the brachial plexus nerves or the axillary and subclavian vessels, and are therefore considered different forms of thoracic outlet syndrome (TOS). In this chapter, current strategies for the diagnosis and treatment of arterial TOS are highlighted, both to avoid serious complications and to promote successful treatment outcomes, including arterial TOS involving the subclavian artery, compressive lesions of the axillary artery and its branches, and some forms of the quadrilateral space syndrome. Although the treatment options to be considered for arterial TOS are similar for all patients, competitive athletes often present special circumstances that need to be taken into account in the decision-making process. With early recognition, proper initial treatment, and definitive surgical care, most competitive athletes affected by arterial TOS can return to previous levels of performance.

Comprehensive surgical management of subclavian vein thrombosis due to venous TOS begins with venography and thrombolysis, followed by anticoagulation and planning for surgery. Surgical treatment revolves around first rib resection and various approaches to achieve a patent subclavian vein, which has an important influence on postoperative care in recovery, rehabilitation, and follow-up. The main concerns during the immediate postoperative hospitalization include the most appropriate anticoagulation regimen, early recognition and intervention for subclavian vein thrombosis, detection and management of lymph leak, pain management, dietary recommendations, monitoring for and treatment of complications, and early implementation of physical therapy. Development and use of a consistent protocol for surgical treatment and early postoperative care is of great value to the surgeon and clinical team responsible for patients with venous TOS.

Postoperative care after surgery for neurogenic TOS is an important consideration in optimizing patient outcomes. This begins with setting appropriate expectations prior to surgery and extends from the immediate postoperative period through outpatient office follow-up. Concerns during the immediate postoperative inpatient hospitalization revolve around attention to the volume and character of drain output, various pharmacological approaches to pain management, dietary recommendations, monitoring for and treatment of common and unusual complications, and early implementation of physical therapy. Development and use of a consistent protocol for early postoperative care is of great benefit to the surgeon and clinical team responsible for patients with neurogenic TOS.

Body weight affects outcomes of surgical treatment for various conditions, but its effects on the treatment of neurogenic thoracic outlet syndrome (NTOS) are unknown. The purpose of this study was to evaluate the influence of body weight on technical and functional outcomes of surgical treatment for NTOS.A retrospective review of prospectively collected data was conducted for 265 patients who underwent supraclavicular decompression for NTOS between January 1, 2014 and March 31, 2016. Patients were grouped according to 6 standard body mass index (BMI) categories. The influence of BMI on measures of surgical outcome was analyzed using Pearson correlation statistics, analysis of variance (ANOVA), and multivariate logistic regression.Mean patient age was 33.3 ± 0.7 years (range, 12-70), and 208 (78%) patients were women. Mean BMI was 27.2 ± 0.4 (range 16.8-49.9), with 7 underweight (3%), 95 normal (36%), 84 overweight (32%), 47 obese-I (18%), 15 obese-II (6%), and 17 obese-III (6%). There was a slight but significant association between BMI and age (Pearson P 0.0001, r = 0.264; ANOVA P = 0.0002), but no correlations between BMI and other preoperative variables. There were no differences between BMI groups for intraoperative, immediate postoperative, or 3-month outcomes. Multivariate logistic regression demonstrated that BMI had no significant effect on functional outcome as measured by the extent of improvement in Disability of the Arm, Shoulder, and Hand score at 3 months (P = 0.429).There was no substantive influence of BMI on preoperative characteristics or intraoperative, postoperative, or 3-month outcomes for patients with NTOS, and no indication of an "obesity paradox" for this condition. Supraclavicular decompression for NTOS achieves similar outcomes across the BMI spectrum.

Arterial thoracic outlet syndrome (TOS) is a rare condition characterized by subclavian artery pathology associated with a bony abnormality. This study assessed contemporary clinical management of arterial TOS at a high-volume referral center.A prospectively maintained database was used to conduct a retrospective review of patients undergoing primary or reoperative treatment for arterial TOS during an 8-year period (2008 to 2016). Presenting characteristics, operative findings, and clinical and functional outcomes were evaluated.Forty patients underwent surgical treatment for arterial TOS, representing 3% of 1401 patients undergoing operations for all forms of TOS during the same interval. Patients were a mean age of 40.3 ± 2.2 years (range, 13-68 years), and 72% were women. More than half presented with upper extremity ischemia/emboli (n = 21) or posterior stroke (n = 2), including eight that had required urgent brachial artery thromboembolectomy. The presentation in 17 (42%) was nonvascular, with 11 having symptoms of neurogenic TOS and six having an asymptomatic neck mass or incidentally discovered subclavian artery dilatation. All patients underwent thoracic outlet decompression (25 supraclavicular, 15 paraclavicular), of which there were 30 (75%) with a cervical rib (24 complete, 6 partial), 5 with a first rib abnormality, 4 with a clavicle fracture, and 1 (reoperation) with no remaining bone abnormality. Subclavian artery reconstruction was performed in 70% (26 bypass grafts, 1 patch, 1 suture repair), and 30% had mild subclavian artery dilatation (100%) requiring no arterial reconstruction. Mean postoperative length of stay was 5.4 ± 0.6 days. During a mean follow-up of 4.5 ± 0.4 years (range, 0.9-8.1 years), subclavian artery patency was 92%, none had further dilatation or embolism, and chronic symptoms were present in six (4 postischemic/vasospasm, 2 neurogenic). Functional outcomes measured by scores on the 11-item version of the Disability of the Arm, Shoulder and Hand Outcome Measure improved from 39.1 ± 3.8 to 19.2 ± 2.7 (P .0001).This relatively large single-institution series demonstrates the diverse clinical presentation of arterial TOS coincident with a spectrum of bony and arterial pathology. Current surgical protocols can achieve excellent outcomes for this rare and often complicated condition.

Background High-performance throwing athletes may be susceptible to the development of neurogenic thoracic outlet syndrome (NTOS). This condition can be career-threatening but the outcomes of treatment for NTOS in elite athletes have not been well characterized. The purpose of this study was to utilize objective performance metrics to evaluate the impact of surgical treatment for NTOS in Major League Baseball (MLB) pitchers. Methods Thirteen established MLB pitchers underwent operations for NTOS between July 2001 and July 2014. For those returning to MLB, traditional and advanced (PitchF/x) MLB performance metrics were acquired from public databases for various time-period scenarios before and after surgery, with comparisons made using paired t-tests, Wilcoxon matched-pair signed-rank tests, and Kruskal–Wallis analysis of variance. Results Ten of 13 pitchers (77%) achieved a sustained return to MLB, with a mean age of 30.2 ± 1.4 years at the time of surgery and 10.8 ± 1.5 months of postoperative rehabilitation before the return to MLB. Pre- and postoperative career data revealed no significant differences for 15 traditional pitching metrics, including earned run average (ERA), fielding independent pitching, walks plus hits per inning pitched (WHIP), walks per 9 innings, and strikeouts to walk ratio (SO/BB). There were also no significant differences between the 3 years before and the 3 years after surgical treatment. Using PitchF/x data for 72 advanced metrics and 25 different time-period scenarios, the highest number of significant relationships (n = 18) was observed for the 8 weeks before/12 weeks after scenario. In this analysis, 54 (75%) measures were unchanged (including ERA, WHIP, and SO/BB) and 14 (19%) were significantly improved, while only 4 (6%) were significantly decreased (including hard pitch maximal velocity 93.1 ± 1.0 vs. 92.5 ± 0.9 miles/hr, P = 0.047). Six pitchers remained active in MLB during the study period, while the other 4 had retired due to factors or injuries unrelated to NTOS. Conclusions Objective performance metrics demonstrate that pitchers returning to MLB after surgery for NTOS have had capabilities equivalent to or better than before treatment. Thoracic outlet decompression coupled with an ample period of postoperative rehabilitation can provide effective treatment for professional baseball pitchers with career-threatening NTOS.

Acidic mammalian chitinase (AMCase) is known to be induced by allergens and helminths, yet its role in immunity is unclear. Using AMCase-deficient mice, we show that AMCase deficiency reduced the number of group 2 innate lymphoid cells during allergen challenge but was not required for establishment of type 2 inflammation in the lung in response to allergens or helminths. In contrast, AMCase-deficient mice showed a profound defect in type 2 immunity following infection with the chitin-containing gastrointestinal nematodes Nippostrongylus brasiliensis and Heligmosomoides polygyrus bakeri. The impaired immunity was associated with reduced mucus production and decreased intestinal expression of the signature type 2 response genes Il13, Chil3, Retnlb, and Clca1. CD103(+) dendritic cells, which regulate T cell homing, were also reduced in mesenteric lymph nodes of infected AMCase-deficient mice. Thus, AMCase functions as a critical initiator of protective type 2 responses to intestinal nematodes but is largely dispensable for allergic responses in the lung.

Objective To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. Methods Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and χ2 analyses. Follow-up results were assessed by changes in 11-item version of Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and patient-rated outcomes. Results Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean ± standard error degree of local tenderness to palpation (1.7 ± 0.1 vs 2.0 ± 0.1; P = .032), the number of positive clinical diagnostic criteria (9.0 ± 0.3 vs 10.1 ± 0.1; P = .001), Cervical-Brachial Symptom Questionnaire scores (68.0 ± 4.1 vs 78.0 ± 2.7; P = .045), and Short-Form 12-item physical quality-of-life scores (35.6 ± 1.5 vs 32.0 ± 0.8; P = .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was −15.6 ± 3.0 (−29.5% ± 5.7%) compared with −29.8 ± 2.4 (−47.9% ± 3.6%) for surgery (P = .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P Conclusions The present study has demonstrated contemporary outcomes for physical therapy and surgery in a well-studied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for ∼90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery.

Congenital anatomic anomalies and variations are frequent in the thoracic outlet and may be associated with clinical symptoms. Arterial thoracic outlet syndrome (TOS) is characterized by subclavian artery compression and vascular pathology, almost always in the presence of a bony abnormality. We describe here a patient with arterial thromboembolism following a fall on the outstretched arm, who was found to have subclavian artery stenosis and post-stenotic dilatation in the absence of a bony abnormality. Surgical exploration revealed a previously undescribed anomaly in which the subclavian artery passed through the costoclavicular space in front of the anterior scalene muscle, where it was subject to bony compression between the first rib and clavicle. Successful treatment was achieved by scalenectomy, first rib resection and interposition bypass graft reconstruction of the affected subclavian artery. This newly acknowledged anatomical variant adds to our understanding of the diverse factors that may contribute to development of TOS.