Contemporary management of arterial thoracic outlet syndrome

<h2>Abstract</h2><h3>Background</h3> Arterial thoracic outlet syndrome (ATOS), although the least common of thoracic outlet syndromes (<1%), often presents with severe upper limb ischemia as a sequel of subclavian artery (SA) dilatation, intimal injury, thrombus formation, and distal embolization, all secondary to extrinsic compression. <h3>Methods</h3> Literature was reivewed to see the changing trends and current managment of ATOS. <h3>Results</h3> The syndrome affects young adults and women more often than men. Although patients often present with a bony prominence in the neck or upper limb ischemia, rarely they may present with posterior circulation stroke or an asymptomatic ATOS may be detected during evaluation of the contralateral limb. Surgical decompression of the thoracic outlet along with treatment of the involved SA is the accepted treatment modality. Arterial thoracic syndrome is almost always operated via the supraclavicular or paraclavicualr and occasionally transaxillary approach. Stenting still does not find any significant role in the treatment of this disease. This review discusses the clinical presentation, evaluation, and surgical therapy including ways to repair the SA. It also discusses the common complications and their management. Finally, the outcomes of surgery for ATOS are discussed. <h3>Conclusions</h3> ATOS can cause significant symptoms and disability. Diagnosis is based on clinical evaluation and imaging and must show evidence of injury to SA. Treatment is surgical and best performed using the supraclavicular or paraclavicular approach and offers good long-term results. A nonculprit first rib may be preserved as evidenced by multiple series showing good medium- to long-term results, and subclavian aneurysm can be treated by different methods.