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Lecoq S, Feuilloy M, Abraham P. Participation of Arterial Ischemia in Positional-Related Symptoms among Patients Referred for Thoracic Outlet Syndrome. J Clin Med 2024; 13:3925. [PMID: 38999490 PMCID: PMC11242123 DOI: 10.3390/jcm13133925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/28/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024] Open
Abstract
Objectives: The coexistence of arterial compression with neurogenic thoracic outlet syndrome (TOS) is associated with a better post-surgical outcome. Forearm transcutaneous oxygen pressure (TcpO2) using the minimal decrease from rest of oxygen pressure (DROPmin) can provide an objective estimation of forearm ischemia in TOS. We hypothesized that a linear relationship exists between the prevalence of symptoms (PREVs) and DROPmin during 90° abduction external rotation (AER) provocative maneuvers. Thereafter, we aimed to estimate the proportion of TOS for which arterial participation is present. Methods: Starting in 2019, we simultaneously recorded forearm TcpO2 recordings (PF6000 Perimed®) and the presence/absence of ipsilateral symptoms during two consecutive 30 s AER maneuvers for all patients with suspected TOS. We retrospectively analyzed the relationship between the prevalence of symptoms and DROPmin results. We estimated the number of cases where ischemia likely played a role in the symptoms, assuming that the relationship should start from zero in the absence of ischemia and increase linearly to a plateau of 100% for the most severe ischemia. Results: We obtained 2560 TcpO2 results in 646 subjects (69% females). The correlation between PREVs and DROPmin was 0.443 (p < 0.001). From these results, we estimated the arterial participation in TOS symptoms to be 22.2% of our 1669 symptomatic upper limbs. Conclusions: TcpO2 appears to be an interesting tool to argue for an arterial role in symptoms in TOS. Arterial participation is frequent in TOS. Whether DROPmin could predict treatment outcomes better than the sole presence of compression is an interesting direction for the future.
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Affiliation(s)
- Simon Lecoq
- Service of Vascular Medicine, University Hospital, 49100 Angers, France;
- Service of Sports Medicine, University Hospital, 49100 Angers, France
| | - Mathieu Feuilloy
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT, University of Angers, 49100 Angers, France;
- School of Electronics (ESEO), 49100 Angers, France
| | - Pierre Abraham
- Service of Vascular Medicine, University Hospital, 49100 Angers, France;
- Service of Sports Medicine, University Hospital, 49100 Angers, France
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT, University of Angers, 49100 Angers, France;
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Nishiyama Y, Yabuuchi K, Nishiyama Y, Kambara Y, Ikushima Y, Enishi T. Crossed raised arm position improves the flow of contrast medium in torso contrast-enhanced computed Tomography. Radiography (Lond) 2024; 30:681-687. [PMID: 38364708 DOI: 10.1016/j.radi.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION This retrospective cohort study examined the effects of the crossed raised arm (CRA) position in contrast-enhanced computed tomography (CECT) on contrast medium influx and image quality relative to the conventional position. METHODS Contrast medium influx into the collateral veins on CECT images was evaluated in 92 participants. The CT values of the pulmonary artery, descending aorta, and spleen were obtained in both positions and compared. Anatomical changes in the diameters and area of the subclavian vein and costoclavicular distance were also analyzed. RESULTS Contras 27 and 6 patients in the conventional and CRA positions, respectively. The influx risk ratio in the CRA position versus that in the conventional position was 0.22 (95% confidence interval, 0.10-0.51). Elevations in the median CT value of the pulmonary artery, descending aorta, and spleen in the CRA position were 7.0% (p < .001), 7.4% (p < .001), and 9.8% (p < .001), respectively. Enlargements in the major and minor diameters of the subclavian vein, subclavian vein area, and costoclavicular distance in the CRA position versus those in the conventional position were 19.3% (p < .001), 28.1% (p < .001), 53.6%, and 30.0% (p < .001), respectively. CONCLUSION The CRA position effectively prevented contrast medium influx into the collateral veins due to SVS and increased CT values in the target organs in CECT. The diameters and area of the subclavian vein and costoclavicular distance were enlarged at the thoracic outlet, which improved the flow of the contrast medium into the targeted organs. IMPLICATIONS FOR PRACTICE The CRA position can contribute to obtaining better CECT images during common clinical assessments at no additional cost.
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Affiliation(s)
- Y Nishiyama
- Department of Radiology, Tokushima Municipal Hospital 2-34 Kitajosanjima, Tokushima 7700812, Japan.
| | - K Yabuuchi
- Department of Radiology, Tokushima Municipal Hospital 2-34 Kitajosanjima, Tokushima 7700812, Japan.
| | - Y Nishiyama
- Graduate School of Biomedical Sciences, Tokushima University 3-18-15 Kuramoto, Tokushima 7708503, Japan.
| | - Y Kambara
- Department of Radiology, Tokushima Municipal Hospital 2-34 Kitajosanjima, Tokushima 7700812, Japan.
| | - Y Ikushima
- Department of Radiology, Tokushima Municipal Hospital 2-34 Kitajosanjima, Tokushima 7700812, Japan.
| | - T Enishi
- Department of Rehabilitation Medicine, Tokushima Municipal Hospital 2-34 Kitajosanjima, Tokushima 7700812, Japan.
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Abraham P, Lecoq S, Mechenin M, Deveze E, Hersant J, Henni S. Role of Lifestyle in Thoracic Outlet Syndrome: A Narrative Review. J Clin Med 2024; 13:417. [PMID: 38256551 PMCID: PMC10816325 DOI: 10.3390/jcm13020417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/20/2023] [Accepted: 01/07/2024] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION The presence of a positional compression of the neurovascular bundle in the outlet between the thorax and the upper limb during arm movements (mainly abduction) is common but remains asymptomatic in most adults. Nevertheless, a certain number of subjects with thoracic outlet positional compression will develop incapacitating symptoms or clinical complications as a result of this condition. Symptomatic forms of positional neurovascular bundle compression are referred to as "thoracic outlet syndrome" (TOS). MATERIALS AND METHODS This paper aims to review the literature and discuss the interactions between aspects of patients' lifestyles in TOS. The manuscript will be organized to report (1) the historical importance of lifestyle evolution on TOS; (2) the evaluation of lifestyle in the clinical routine of TOS-suspected patients, with a description of both the methods for lifestyle evaluation in the clinical routine and the role of lifestyle in the occurrence and characteristics of TOS; and (3) the influence of lifestyle on the treatment options of TOS, with a description of both the treatment of TOS through lifestyle changes and the influence of lifestyle on the invasive treatment options of TOS. RESULTS We report that in patients with TOS, lifestyle (1) is closely related to anatomical changes with human evolution; (2) is poorly evaluated by questionnaires and is one of the factors that may induce symptoms; (3) influences the sex ratio in symptomatic athletes and likely explains why so many people with positional compression remain asymptomatic; and (4) can sometimes be modified to improve symptoms and potentially alter the range of interventional treatment options available. CONCLUSIONS Detailed descriptions of the lifestyles of patients with suspected TOS should be carefully analysed and reported.
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Affiliation(s)
- Pierre Abraham
- Service of Sports Medicine, University Hospital, 49100 Angers, France;
- Service of Vascular Medicine, University Hospital, 49100 Angers, France (J.H.)
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT, University Angers, 49100 Angers, France
| | - Simon Lecoq
- Service of Sports Medicine, University Hospital, 49100 Angers, France;
- Service of Vascular Medicine, University Hospital, 49100 Angers, France (J.H.)
| | - Muriel Mechenin
- Service of Vascular Medicine, University Hospital, 49100 Angers, France (J.H.)
| | - Eva Deveze
- Service of Thoracic and Vascular Surgery, University Hospital, 49100 Angers, France
| | - Jeanne Hersant
- Service of Vascular Medicine, University Hospital, 49100 Angers, France (J.H.)
| | - Samir Henni
- Service of Vascular Medicine, University Hospital, 49100 Angers, France (J.H.)
- INSERM, CNRS, MITOVASC, Equipe CarMe, SFR ICAT, University Angers, 49100 Angers, France
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Hersant J, Lecoq S, Ramondou P, Feuilloy M, Abraham P, Henni S. Upper arm versus forearm transcutaneous oximetry during upper limb abduction in patients with suspected thoracic outlet syndrome. Front Physiol 2022; 13:1033137. [DOI: 10.3389/fphys.2022.1033137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022] Open
Abstract
Context: Thoracic outlet syndrome (TOS) is common among athletes and should be considered as being of arterial origin only if patients have “clinical symptoms due to documented symptomatic ischemia.” We previously reported that upper limb ischemia can be documented with DROPm (minimal value of limb changes minus chest changes) from transcutaneous oximetry (TcpO2) in TOS.Purpose: We aimed to test the hypothesised that forearm (F-) DROPm would better detect symptoms associated with arterial compression during abduction than upper arm (U-) DROPm, and that the thresholds would differ.Methods: We studied 175 patients (retrospective analysis of a cross-sectional acquired database) with simultaneous F-TcpO2 and U-TcpO2 recordings on both upper limbs, and considered tests to be positive (CS+) when upper limb symptoms were associated with ipsilateral arterial compression on either ultrasound or angiography. We determined the threshold and diagnostic performance with a receiver operating characteristic (ROC) curve analysis and calculation of the area under the ROC curve (AUROC) for absolute resting TcpO2 and DROPm values to detect CS+. For all tests, a two-tailed p < 0.05 was considered indicative of statistical significance.Results: In the 350 upper-limbs, while resting U-TcpO2 and resting F-TcpO2 were not predictive of CS + results, the AUROCs were 0.68 ± 0.03 vs. 0.69 ± 0.03 (both p < 0.01), with the thresholds being −7.5 vs. −14.5 mmHg for the detection of CS + results for U-DROPm vs. F-DROPm respectively.Conclusion: In patients with suspected TOS, TcpO2 can be used for detecting upper limb arterial compression and/or symptoms during arm abduction, provided that different thresholds are used for U-DROPm and F-DROPm.Clinical Trial Registration:ClinicalTrials.gov, identifier NCT04376177.
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Relationships between the Clinical Test Results and Neurophysiological Findings in Patients with Thoracic Outlet Syndrome. Bioengineering (Basel) 2022; 9:bioengineering9100598. [PMID: 36290565 PMCID: PMC9598481 DOI: 10.3390/bioengineering9100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022] Open
Abstract
A thoracic outlet syndrome (TOS) is the type of brachial plexus disorder most difficult to objectively assess using a clinical examination and differential diagnosis. Its symptoms can be frequently misdiagnosed, especially among others with cervical disc-root conflicts, plexopathies, and peripheral neuropathies. In this study, we aim to identify the correlations between positive Doppler ultrasonography results indicating pathological changes in the subclavian flow velocity, clinical tests, and chosen clinical neurophysiology recordings as proposed alternative or supplementary diagnostic tools for evaluating TOS patients. Sixty TOS patients with positive Doppler ultrasonography and Roos test results and sixty healthy people as a control group were bilaterally examined, and the results were compared. Pain intensity was assessed using a visual analogue scale (VAS). Sensory perceptions within C4–C8 dermatomes were assessed with Von Frey filament (FvF) tests. The activity of motor units in the proximal and distal muscles of the upper extremities was evaluated using surface electromyography (sEMG) during maximal contractions before and after a provocative raised hands test (RHT). An electroneurography (ENG) was used to evaluate the transmission of nerve impulses peripherally. Motor evoked potential (MEP) recordings, induced by the over-vertebral magnetic stimulation of the C5–C7 neuromeres, were used to examine motor transmissions from the cervical motor centres to the upper extremities muscles. The results revealed a relationship between positive Doppler test scores and pathological changes in the subclavian flow velocity through the results of the following diagnostic tools: a VAS score of 1.9 was detected on average, superficial sensory perception abnormalities were found in the innervation areas of the ulnar nerves detected by FvF tests, a decrease in the amplitudes of sEMG recordings was seen in distal rather than proximal muscles (especially following the RHT), a decrease in the motor and sensory peripheral transmissions of nerve impulses in the median, ulnar and cutaneous anterobrachial median nerves was seen, as well as MEP amplitudes recorded from the abductor pollicis brevis muscle. The provocative RHT combined with sEMG and MEP recordings can be considered accurate and objective clinical neurophysiology tools that could supplement the commonly used clinical tests. Such an approach may result in a more precise neurogenic TOS diagnostic algorithm.
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Pesser N, de Bruijn BI, Goeteyn J, Verhofstad N, Houterman S, van Sambeek MRHM, Thompson RW, van Nuenen BFL, Teijink JAW. Reliability and Validity of the Standardized Elevated Arm Stress Test in the diagnosis of Neurogenic Thoracic Outlet Syndrome. J Vasc Surg 2022; 76:821-829.e1. [PMID: 35561941 DOI: 10.1016/j.jvs.2022.03.885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We developed a standardized elevated arm stress test (EAST)-meter to standardize posture and measure additional grip and fatigue parameters. This study aims to determine the reliability and validity of the standardized EAST (sEAST) in the diagnosis of neurogenic thoracic outlet syndrome (NTOS). DESIGN Prospective cohort study METHODS: Patients evaluated for NTOS between October 2018 and February 2020 were included and performed the sEAST. Patients were classified into a proven NTOS group or a symptomatic control group using the Reporting Standards for NTOS and outcome of thoracic outlet decompression (TOD) surgery. Healthy subjects were recruited as asymptomatic control group. Test-retest reliability, the area under the curve (AUC), and positive and negative predictive values were calculated for each valuable sEAST-parameter. RESULTS A total of 426 suspected NTOS patients and 147 healthy controls performed the sEAST measurement. The validity analysis was performed with 111 proven NTOS patients, 94 symptomatic controls and 147 asymptomatic controls. The reporting standards were inconclusive in 116 patients, 77 patients were excluded because TOD surgery was not performed or unsuccessful, and 28 patients were excluded with arterial or venous TOS. The AUC of proven NTOS compared to asymptomatic controls ranged between 0.59 and 0.77, and between 0.54 and 0.63 when compared to symptomatic controls. The positive predictive value ranged between 46% and 65%, and the negative predictive value between 51% and 66%. Test-retest reliability analysis in 80 patients with multiple sEAST measurements showed moderate to good (0.52-0.87) ICC values for duration and grip strength parameters. Grip fatigue parameters demonstrated poor (0.46-0.16) ICC values. CONCLUSION The sEAST showed good test-retest reliability for duration and grip strength parameters. However, the discriminative value of all sEAST-parameters is low in NTOS diagnostics. The good test-retest reliability of the sEAST parameters make them valuable outcome measures for comparison in a diagnostic care pathway.
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Affiliation(s)
- Niels Pesser
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Britt I de Bruijn
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; Physical Therapy Sciences, program in Clinical Health Sciences, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jens Goeteyn
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Nicole Verhofstad
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Saskia Houterman
- Department of education and research, Catharina Hospital, Eindhoven, The Netherlands
| | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Biomedical Technology, University of Technology Eindhoven, Eindhoven, The Netherlands
| | - Robert W Thompson
- The Centre for Thoracic Outlet Syndrome and the Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, USA
| | | | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands.
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Hersant J, Lecoq S, Ramondou P, Papon X, Feuilloy M, Abraham P, Henni S. Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome. Front Physiol 2022; 13:726315. [PMID: 35222068 PMCID: PMC8874319 DOI: 10.3389/fphys.2022.726315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Thoracic outlet syndrome (TOS) should be considered of arterial origin only if patients have clinical symptoms that are the result of documented symptomatic ischemia. Simultaneous recording of inflow impairment and forearm ischemia in patients with suspected TOS has never been reported to date. We hypothesized that ischemia would occur in cases of severely impaired inflow, resulting in a non-linear relationship between changes in pulse amplitude (PA) and the estimation of ischemia during provocative attitudinal upper limb positioning. Design Prospective single center interventional study. Material Fifty-five patients with suspected thoracic outlet syndrome. Methods We measured the minimal decrease from rest of transcutaneous oximetry pressure (DROPm) as an estimation of oxygen deficit and arterial pulse photo-plethysmography to measure pulse amplitude changes from rest (PA-change) on both arms during the candlestick phase of a “Ca + Pra” maneuver. “Ca + Pra” is a modified Roos test allowing the estimation of maximal PA-change during the “Pra” phase. We compared the DROPm values between deciles of PA-changes with ANOVA. We then analyzed the relationship between mean PA-change and mean DROPm of each decile with linear and second-degree polynomial (non-linear) models. Results are reported as median [25/75 centiles]. Statistical significance was p < 0.05. Results DROPm values ranged −11.5 [−22.9/−7.2] and − 12.3 [−23.3/−7.4] mmHg and PA-change ranged 36.4 [4.6/63.8]% and 38.4 [−2.0/62.1]% in the right and left forearms, respectively. The coefficient of determination between median DROPm and median PA-change was r2 = 0.922 with a second-degree polynomial fitting, but only r2 = 0.847 with a linear approach. Conclusion Oxygen availability was decreased in cases of severe but not moderate attitudinal inflow impairments. Undertaking simultaneous A-PPG and forearm oximetry during the “Ca + Pra” maneuver is an interesting approach for providing objective proof of ischemia in patients with symptoms of TOS suspected of arterial origin.
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Affiliation(s)
| | - Simon Lecoq
- Vascular Medicine, University Hospital, Angers, France
| | - Pierre Ramondou
- Vascular Medicine, University Hospital, Angers, France
- UMR CNRS 1083 INSERM 6015, LUNAM University, Angers, France
| | - Xavier Papon
- Service of Thoracic and Vascular Surgery, University Hospital, Angers, France
| | - Mathieu Feuilloy
- School of Electronics (ESEO), Angers, France
- UMR CNRS 6613 LAUM, Le Mans, France
| | - Pierre Abraham
- Vascular Medicine, University Hospital, Angers, France
- UMR CNRS 1083 INSERM 6015, LUNAM University, Angers, France
- Sports and Exercise Medicine, University Hospital, Angers, France
- *Correspondence: Pierre Abraham,
| | - Samir Henni
- Vascular Medicine, University Hospital, Angers, France
- UMR CNRS 1083 INSERM 6015, LUNAM University, Angers, France
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Huang J, Lauer J, Zurkiya O. Arterial thoracic outlet syndrome. Cardiovasc Diagn Ther 2021; 11:1118-1124. [PMID: 34815963 DOI: 10.21037/cdt-20-149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
Thoracic outlet syndrome (TOS) is used to describe the constellation of symptoms arising from neurovascular compression of the thoracic outlet. The structures passing through the thoracic outlet include the subclavian artery, subclavian vein and trunks of the brachial plexus. Patients may experience symptoms related to compression of any one or various combinations of these structures. Arterial pathology as the cause of TOS is rare, though repetitive overhead arm motion, such as seen in athletes, is a risk factor for developing arterial TOS (aTOS). Symptoms include chronic findings, such as pallor, arm claudication or cool arm. Currently diagnosis of aTOS is made using clinical and imaging parameters which include focused history and physical including provocative maneuvers and imaging follow-up ranging from angiography to MRI. Occasionally, acute thrombosis can result in limb threatening ischemia requiring emergent catheter directed thrombolysis. Outside of acute limb ischemia, management of aTOS is variable, however typically begins with conservative measures such as physical therapy. In patients who do not respond or progress on conservative management, surgical decompression may be performed. Open or endovascular treatment of subclavian artery pathology may be necessary for recalcitrant cases. In this article, the aim is to review the elements involving diagnosis and management of aTOS.
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Affiliation(s)
- Junjian Huang
- Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Jason Lauer
- Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Omar Zurkiya
- Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Goeteyn J, Pesser N, van Sambeek MRHM, Thompson RW, van Nuenen BFL, Teijink JAW. Duplex Ultrasound Studies Are Neither Necessary or Sufficient for the Diagnosis of Neurogenic Thoracic Outlet Syndrome. Ann Vasc Surg 2021; 81:232-239. [PMID: 34775011 DOI: 10.1016/j.avsg.2021.09.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/17/2021] [Accepted: 09/25/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Jens Goeteyn
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Niels Pesser
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Biomedical Technology, University of Technology Eindhoven, Eindhoven, The Netherlands
| | - Robert W Thompson
- Department of Surgery, Center for Thoracic Outlet Syndrome, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
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Hersant J, Ramondou P, Thouveny F, Daligault M, Feuilloy M, Saulnier P, Abraham P, Henni S. Arterial Digital Pulse Photoplethysmography in Patients with Suspected Thoracic Outlet Syndrome: A Study of the "Ca+Pra" Maneuver. Diagnostics (Basel) 2021; 11:diagnostics11061128. [PMID: 34205560 PMCID: PMC8234081 DOI: 10.3390/diagnostics11061128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022] Open
Abstract
The level of pulse amplitude (PA) change in arterial digital pulse plethysmography (A-PPG) that should be used to diagnose thoracic outlet syndrome (TOS) is debated. We hypothesized that a modification of the Roos test (by moving the arms forward, mimicking a prayer position (“Pra”)) releasing an eventual compression that occurs in the surrender/candlestick position (“Ca”) would facilitate interpretation of A-PPG results. In 52 subjects, we determined the optimal PA change from rest to predict compression at imaging (ultrasonography +/− angiography) with receiver operating characteristics (ROC). “Pra”-PA was set as 100%, and PA was expressed in normalized amplitude (NA) units. Imaging found arterial compression in 23 upper limbs. The area under ROC was 0.765 ± 0.065 (p < 0.0001), resulting in a 91.4% sensitivity and a 60.9% specificity for an increase of fewer than 3 NA from rest during “Ca”, while results were 17.4% and 98.8%, respectively, for the 75% PA decrease previously proposed in the literature. A-PPG during a “Ca+Pra” test provides demonstrable proof of inflow impairment and increases the sensitivity of A-PPG for the detection of arterial compression as determined by imaging. The absence of an increase in PA during the “Ca” phase of the “Ca+Pra” maneuver should be considered indicative of arterial inflow impairment.
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Affiliation(s)
- Jeanne Hersant
- Vascular Medicine Department, University Hospital in Angers, 49100 Angers, France; (J.H.); (P.R.); (S.H.)
- University Angers, UMR CNRS 6015-INSERM 1083, MITOVASC, SFR ICAT, 49045 Angers, France;
| | - Pierre Ramondou
- Vascular Medicine Department, University Hospital in Angers, 49100 Angers, France; (J.H.); (P.R.); (S.H.)
- University Angers, UMR CNRS 6015-INSERM 1083, MITOVASC, SFR ICAT, 49045 Angers, France;
| | - Francine Thouveny
- Radiology Department, University Hospital in Angers, 49100 Angers, France;
| | - Mickael Daligault
- University Angers, UMR CNRS 6015-INSERM 1083, MITOVASC, SFR ICAT, 49045 Angers, France;
- Thoracic and Vascular Surgery Department, University Hospital in Angers, 49100 Angers, France
| | - Mathieu Feuilloy
- School of Electronics (ESEO), Universite catholique de l’ouest, 49100 Angers, France;
- University Le Mans, LAUM CNR S6613, 72000 Le Mans, France
| | - Patrick Saulnier
- University Angers, Inserm, 1066 CNRS 6021, MINT, SFR ICAT, F-49045 Angers, France;
- Biostatistics Department, University Hospital in Angers, 49100 Angers, France
| | - Pierre Abraham
- University Angers, UMR CNRS 6015-INSERM 1083, MITOVASC, SFR ICAT, 49045 Angers, France;
- Sports and Exercise Medicine Department, University Hospital in Angers, 49100 Angers, France
- Correspondence: ; Tel.: +33-(0)2-41-35-40-93
| | - Samir Henni
- Vascular Medicine Department, University Hospital in Angers, 49100 Angers, France; (J.H.); (P.R.); (S.H.)
- University Angers, UMR CNRS 6015-INSERM 1083, MITOVASC, SFR ICAT, 49045 Angers, France;
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11
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Abraham P, Hersant J, Ramondou P, Thouveny F, Feuilloy M, Picquet J, Henni S. Comparison of transcutaneous oximetry with symptoms and arteriography in thoracic outlet syndrome. Clin Hemorheol Microcirc 2020; 75:107-119. [PMID: 31929152 DOI: 10.3233/ch-190751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Non-invasive tests are still required to improve the holistic diagnostic approach of thoracic outlet syndrome (TOS). OBJECTIVES We aimed to analyze the diagnostic accuracy of the decrease from rest oxygen pressure (DROP) index of transcutaneous oximetry (TcpO2) in TOS. METHODS Seventy-six patients and 40 asymptomatic volunteers (Controls) were enrolled. In TOS-suspected patients, the arteriograms were investigated for the presence of≥75% stenosis. The area under receiver operating characteristics curve (AUC) analysis tested the ability of forearm TcpO2 during provocative maneuvers to discriminate patients from controls and, to predict a positive arteriographic findings in the 44 TOS-suspected patients that had an arteriography. RESULTS The media [25/75° centile] DROP values of controls and patients were -14 [-8/-22] mmHg and -22 [-12/-42] mmHg, respectively (p for Mann-Whitney<0.02). AUC analysis showed a significant ability of TcpO2 to predict the presence of subclavian arterial compression on arteriography (AUC, 0.694). CONCLUSIONS Although time consuming, tcpO2 is independent of the observer expertise and could be useful in TOS-suspected patients to select the patients that should undergo arteriography.
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Affiliation(s)
- Pierre Abraham
- Exercise investigation and Sports Medicine, University Hospital, Angers, France.,UMR CNRS 6015, INSERM 1228, Medical School, University of Angers, France
| | | | | | | | | | - Jean Picquet
- UMR CNRS 6015, INSERM 1228, Medical School, University of Angers, France.,Thoracic and Vascular Surgery, University Hospital, Angers, France
| | - Samir Henni
- UMR CNRS 6015, INSERM 1228, Medical School, University of Angers, France.,Vascular Radiology, University Hospital, Angers, France
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12
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Hersant J, Ramondou P, Guilleron C, Picquet J, Henni S, Abraham P. A pilot study of forearm microvascular impairment and pain while using a telephone. Microvasc Res 2019; 129:103963. [PMID: 31790665 DOI: 10.1016/j.mvr.2019.103963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine if using a telephone can induce forearm pain and ischemia. DESIGN Prospective case-control trial. SETTING Vascular laboratory in the university hospital in Angers between September 2018 and March 2019. PARTICIPANTS Fifteen apparently healthy subjects (controls) and 32 patients with suspected thoracic outlet syndrome (TOS) of vascular or non-vascular origin. INTERVENTION Hand-holding a cellular phone to answer a call from investigators. MAIN OUTCOME MEASURES Presence of forearm fatigue or pain (primary outcome), ability to hold the phone with each hand for 1 min (secondary outcome 1) and decrease in forearm transcutaneous oxygen pressure DROP index indicating forearm ischemia (secondary outcome 2). A DROP < -15 mm Hg defined ischemia. RESULTS Answering a phone call resulted in 25(78%) patients with forearm fatigue or pain and in 18 (56%) cases in the inability to hold the phone for 1 min, on one or both arms in patients with suspected TOS, but never occurred in healthy volunteers (p < .05 and p < .001). The presence of ischemia was observed in one or both arms in 10 (31%) patients with proved TOS and was always associated to phone-induced pain. Three (20%) of the controls had phone-induced ischemia. All had asymptomatic TOS and remained asymptomatic during the phone test (p = .42 from suspected-TOS patients). CONCLUSION The phone conversation resulted in pain in many patients with suspected TOS. Transcutaneous oximetry can document the underlying ischemia. Forearm phone-call-induced pain may be indicative of TOS provided that no earplug or headset is used. Trial registrationClinicalTrials.govNCT03355274.
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Affiliation(s)
- Jeanne Hersant
- Vascular Medicine, University Hospital Center, Angers, France
| | - Pierre Ramondou
- Vascular Medicine, University Hospital Center, Angers, France; Sports Medicine, University Hospital Center, Angers, France
| | - Celine Guilleron
- Sports Medicine, University Hospital Center, Angers, France; Laboratory Movement Interactions performance; MIP EA4334, F-72000 Le Mans, France
| | - Jean Picquet
- Vascular and thoracic surgery, University Hospital Center, Angers, France; UMR INSERM 1083-CNRS 6015, Mitovasc Institute, Angers, France
| | - Samir Henni
- Vascular Medicine, University Hospital Center, Angers, France; UMR INSERM 1083-CNRS 6015, Mitovasc Institute, Angers, France
| | - Pierre Abraham
- Vascular Medicine, University Hospital Center, Angers, France; Sports Medicine, University Hospital Center, Angers, France; UMR INSERM 1083-CNRS 6015, Mitovasc Institute, Angers, France.
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