Our multidisciplinary teams work together to offer highly individualized treatment, all in the best interest of patients with TOS. Surgical options include decompression surgery to remove the first rib via transaxillary, supraclavicular or infraclavicular approaches. 

To schedule an evaluation with a Frankel Cardiovascular Center physician, call 888-287-1082. Or visit the Make a Cardiovascular Appointment page to learn what to expect when you call us.

What are the symptoms of NTOS?

• Pain, numbness and tingling, weakness, discoloration, temperature changes in the arm, hand and fingers, and the forearm.
• Pain and tingling in the surrounding areas such as the base of the neck, chest wall, axilla (armpit), breast, upper back and head.
• Worsening of the above symptoms with the arm overhead (for example, brushing your hair) or with the arm dangling (for example, carrying heavy objects).

What are the symptoms of VTOS?

• Patients may have some symptoms that are similar to NTOS.
• If the vein clots off (thromboses), patients will have a blue, swollen arm with significant discomfort.
• Patients with VTOS with a vein that has not thrombosed typically have arm swelling, fullness, heaviness, aching and a change in color with overhead activity.

What are symptoms of ATOS?

Patients may experience symptoms that are similar to NTOS. They may also experience:

• A pulsating mass above the collarbone.
• Exercise-induced arm discomfort resulting from insufficient blood flow to the arm.
• Pain, numbness, tingling, cold sensation, pale/mottled hand or fingers with black spots, fingertip ulceration or gangrene.

How is NTOS diagnosed?

There is no definitive test to diagnosis NTOS. However, there are tests that are useful to rule out other conditions that may cause similar symptoms. These include:

• Electromyography (EMG) to evaluate for peripheral nerve entrapment.
• MRI to evaluate for cervical spine disease (e.g., cervical pinched nerve) or intrinsic shoulder disease (for example, torn rotator cuff).
• X-ray of the cervical spine to evaluate for a cervical rib.

How is VTOS diagnosed?

The diagnosis of VTOS is supported by the following studies:

• Dynamic CT venogram/MR venogram: These non-invasive studies look at compression and obstruction of the subclavian vein (with the patient's arm in a neutral position and elevated). If the vein is clotted or becomes occluded with overhead activity, this supports the diagnosis.
• Venogram with possible lysis (a procedure in which clot-dissolving drugs are delivered to the site of a clot through a catheter): In patients with a clotted subclavian vein, this study allows for the removal of a clot and confirmation of the diagnosis.

How is ATOS diagnosed?

The diagnosis of ATOS is supported by:

• Dynamic CT/MR Arteriogram: These are non-invasive studies that look at compression and patency of the subclavian artery while the arm is in a neutral position and elevated.
• Arteriogram with possible lysis: In patients with a clotted subclavian artery, this study allows for removal of clot and confirmation of the diagnosis.

How is NTOS treated?

The initial treatment includes a course of physical and occupational therapy focused on improving flexibility and to relieve tension and discomfort. If patients do not improve with therapy, thoracic outlet decompression is recommended. This involves removal of the first rib, surrounding muscle and scar tissue around the jugular and subclavian veins.

Following surgery, patients have a short inpatient hospital stay and then are discharged home, active and able to perform daily activities. During the next few months, a comprehensive physical and occupational therapy program allows patients to resume unrestricted activity. Patients follow a pre-set medication taper regimen so they are off all post-operative medications by six months.

How is VTOS treated?

If the vein is clotted, patients typically undergo a clot-dissolving procedure to remove the vein obstruction and a workup to confirm the diagnosis. Occasionally, blood tests are required to rule out other causes of clotting. Following restoration of blood flow, surgery is performed in 2-6 weeks depending on results of the venogram. Surgery includes a complete anterior and middle scalenectomy, resection of the entire first rib and removal of the subclavius muscle. In some instances, intraoperative venography with reconstruction of the subclavian vein is needed. 

Following surgery, patients have a short inpatient hospital stay and then are discharged home, active and able to perform daily activities. During the next few months, a comprehensive physical and occupational therapy program to allow patients to resume unrestricted activity. Patients follow a pre-set medication taper regimen so that patients are off all post-operative medications by six months.

How is ATOS treated?

Patients who present with acute/subacute upper extremity ischemia will need restoration of blood flow through lysis or through open surgery followed by a thoracic outlet decompression with a complete anterior and middle scalenectomy, resection of the entire first rib and possible arterial reconstruction. Patients with an incidentally found pulsating mass, a subclavian aneurysm or arm claudication will need a thoracic outlet decompression and possible arterial reconstruction.

Following surgery, patients have an inpatient hospital stay and then are discharged home, active and able to perform daily activities. During the next few months, a comprehensive physical and occupational therapy program allows patients to resume unrestricted activity. Patients follow a pre-set medication taper regimen such that patients are off all post-operative medications by six months.

• Thoracic Outlet Syndrome Patient Information Guide
• Learn about Thoracic Outlet Syndrome in the U-M Health Patient Education Library