All Posts tagged TOS

First Report Of Internal Jugular Vein Narrowing— A New Concept In Thoracic Outlet Syndrome


We have dedicated a number of recent posts to the discussion of thoracic outlets syndrome (TOS), a condition which causes compression of the blood vessels and nerves at the top of the chest. Drs. Sam Ahn and Robert Feldtman of DFW Vascular, along with other colleagues, study this condition and recently found that compression (stenosis) of the internal jugular vein is found in patients with TOS.

This finding represents a new concept in the diagnosis of this often debilitating condition. Furthermore, the authors reported that using a balloon on the tip of a catheter to expand the compression or blockage in the jugular and/or subclavian veins can relieve symptoms of TOS. This new concept will be presented to other surgeons at the Fall semi-annual meeting of The Texas Surgical Society to be held this September in Houston (

Below is the abstract of the scientific paper to be presented at the meeting.

TITLE: Percutaneous Transluminal Angioplasty as Therapy for Thoracic Outlet Symptoms

AUTHORS: Ahn, Samuel S; Chen, Julia F;  Miller, Travis J.; Chen, Sheena W.; Feldtman, Robert; Hwang, William

OBJECTIVES: Traditionally, thoracic outlet syndrome (TOS) has been associated with axillo-subclavian  vein stenosis without any mention of the internal jugular (IJ) vein.  However, we recently reported a high prevalence of IJ stenosis in 109 patients with TOS in a limited study.  To further understand the clinical significance of this finding, we analyzed a larger cohort of patients and their subsequent follow-up.

METHODS:  We retrospectively analyzed 237 consecutive unique patients referred to our practice with thoracic outlet syndrome. From April ’08 to Dec ’12, all patients underwent diagnostic brachiocephalic venograms. Average age was 49.9 years (r:17 to 81), with 71.8% females and 28.2% male. We looked at the right and left internal jugular veins and the right and left subclavian veins. Stenoses were classified into high (>66%), medium (33%-66%),and  low (<33%). We also looked for presence of collaterals around the obstructions.  Venogram findings were independently confirmed by four investigators.  For the purposes of this analysis, high stenosis was considered significant. Medium and low stenoses were considered significant only if there were visible collaterals.  Of this group, we then looked at all patients who received intervention via PTA at the stenosed IJ sites.  Patients were categorized into Groups I or II.  Group I: patients who received no immediate relief of symptoms after PTA; Group II: patients who did receive immediate relief of symptoms after PTA.  Group II was further broken down into subgroups IIA, IIB, and IIC.  Group IIA: those who required additional surgical intervention due to symptom recurrence; Group IIB: those who report sustained relief; Group IIC: those who were lost to follow-up.

RESULTS:  Left internal jugular vein stenosis, left subclavian vein stenosis, right internal jugular vein stenosis, and right subclavian vein stenosis was seen in 67.5%, 57.6%, 62.7%, and 61.6% of patients, respectively. Internal jugular vein stenosis was not present in 18.1% of patients, present unilaterally in 33.3% of patients, and present bilaterally in 48.5% of patients. Subclavian vein stenosis was not present in 24.1% of patients, present unilaterally in 32.5% of patients, and present bilaterally in 43.5% of patients. Significant collaterals were present in 26.80% of high stenosis, 21.5% of medium and 12.8% of low.  Of 237 patients, 67.7% (n=147) received PTA intervention.  Of those who received intervention, 28.6% (n=42) were in Group I, 67.4% (n=99) were in Group II, and 4% (n=6) did not have available data.  Of those in Group II, the breakdown was as follows:  IIA (35%, n=34) with a median of less than 7 days (r: 2-210) of relief; IIB (31%, n=31) with 120 days (r: 5 to 406) of follow-up; IIIC (31%, n=31) with 93.5% (n=29) reporting sustained relief at 7-day follow-up and median follow-up of 7 days (avg: 25, r: 6-182).

CONCLUSIONS: Internal jugular vein stenosis is common in patients with thoracic outlet symptoms and percutaneous treatment provides benefit to some patients.  These findings could fundamentally change the diagnosis and treatment of thoracic outlet syndrome.  Further studies are warranted.

If you have numbness or tingling in the arms or hands, call DFW Vascular to schedule a consultation with one of our expert surgeons.

Dodger Pitcher Undergoes Surgery For Thoracic Outlet Syndrome


Earlier this week, Los Angeles Dodger pitcher Josh Beckett underwent surgery to remove his right first rib. Why does a pitcher need to have a first rib removed? The reason relates to thoracic outlet syndrome, a condition in which nerves and blood vessels are compressed by the anatomy at the top of the chest cavity. As was the case with Mr. Beckett, many patients with thoracic outlet syndrome often present with numbness and tingling in their arm and hand. While a number of patients need invasive surgery, the surgeon experts at DFW Vascular may be able to use minimally invasive office-based techniques to treat the condition.

To learn more about DFW surgeons Drs. Samuel Ahn and Robert Feldtman recent presentation of their research (performed in collaboration with other physicians) in the area of thoracic outlet syndrome, please look at our most recent post, “What is Thoracic Outlet Syndrome?”

If you suffer from numbness and tingling in your arm and hand, or have been told you may have thoracic outlet syndrome, please call DFW Vascular today to schedule a consultation.


What is Thoracic Outlet Syndrome?


Thoracic Outlet Syndrome (TOS) is a condition in which there is compression or pressure on the nerves and blood vessels at the top of the thoracic (chest) cavity. The syndrome can present with a number of different signs and symptoms, but most who suffer complain of persistent pain. Drs. Samuel Ahn and Robert Feldtman of DFW Vascular are experts in the diagnosis and treatment of this condition and recently shared new research in this field to other vascular surgeons attending the 2013 Society for Vascular Surgery (SVS). Their work, performed in conjunction with their collaborators, evaluated how blockages in the internal jugular vein play a role in this condition. The authors studied just under 250 patients for over a 4-year period and analyzed the data to look for relationships between this jugular vein blockage and the condition. The authors reported that internal jugular vein blockage is common in these patients and may contribute to their symptoms. Importantly, the authors also stated that patients experienced temporary benefits in symptoms after using catheter-based balloons to inflate the areas of blockage. In the accompanying slides, one can see a few key points of this important research.

  1. The first slide documents the anatomy of the thoracic outlet and notes the compression of key structures.
  2. Using dye being photographed through the veins, one can see where blockage occurs.
  3. Using special catheters, a balloon is inflated at the site of compression (Left with blockage, right post balloon expansion)
  4. Compression of the internal jugular vein is common in TOS and balloon expansion may help with symptoms.

Further work on the causes and treatment of TOS will continue in an effort to bring relief to the patients suffering from this condition. If you have persistent arm and neck pain, or suffer from persistent headaches, call DFW Vascular today and set up an appointment to meet with one of their surgeons. A straight-forward, office-based (outpatient) procedure may be the solution to years of pain and discomfort.

Click here for more information on TOS from the Society for Vascular Surgery, or view Dr. Feldtman’s presentation.