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The clinical presentation of the thoracic outlet syndrome (TOS) depends on the specific structures compressed, giving rise to three distinct conditions: neurogenic TOS, venous TOS, and arterial TOS. All three types are rare conditions, and diagnosis dependd on clinical suspicion, pattern recognition, and exclusion of more common diseases that have overlapping features. A provisional diagnosis can usually be made or excluded on the basis of clinical…
Thoracic outlet syndrome (TOS) arises when structures in the thoracic outlet are compromised. Although it is commonly considered as one entity, TOS actually consists of three distinct conditions: neurogenic TOS, venous TOS, and arterial TOS. All three have different pathophysiology, manifest with different symptoms, have different underlying anatomic abnormalities, and require subtly different treatment. TOS is estimated to affect approximately 5000 patients per year worldwide. Neurogenic…
Alexander performed the first cervical sympathectomy in 1889. A little more than a quarter of a century later, thoracic sympathectomy (TS) for hyperhidrosis became popular. Kotzareff was credited with the first TS for hyperhidrosis, and it was found that surgery contributes to anhidrosis from the nipple line upward. The role of TS has since expanded to include spastic paralysis to decreased muscle tone, and vasospastic conditions…
Understanding the pathophysiology and management of extremity causalgia, a complex regional pain syndrome (CPRS), is relevant to the practice of vascular surgery. Patient referrals for extremity complaints (pain, cyanosis, skin temperature changes, edema) can mimic arterial and venous disease, but once a vascular abnormality is excluded, a neurogenic basis for the symptom complex should be considered. Reflex sympathetic dystrophy (RSD), a type I CRPS, displays specific…
Vasospasm of the upper extremities is most commonly caused by Raynaud’s syndrome, but it can also result from medications such as ergot compounds, acrocyanosis, livedo reticularis, or intraarterial injections. Raynaud’s Syndrome Raynaud’s syndrome is the most common vasospastic disorder seen in clinical practice. Maurice Raynaud in the late 1800s first described this condition as bilateral symmetric gangrene. At the time, it was referred to as Raynaud’s…
Symptomatic arterial disease of the upper extremity is uncommon, accounting for approximately 5% of all cases of extremity ischemia. Ischemia in the upper extremity is caused by a wide variety of diseases, many of which are both nonatherosclerotic and systemic in nature. Occupational, pharmacologic, medical, and athletic factors contribute to many of these diseases. Manifestations of arm ischemia include Raynaud’s phenomenon, pain, and claudication. Embolic symptoms…
Upper extremity arterial disease is relatively uncommon. Unlike lower extremity disease, where the cause is predominantly atherosclerotic and the patients older, upper extremity arterial pathology is far more diverse and often affects younger persons ( Box 1 ). Treatment modalities for these pathologies vary considerably, making a correct diagnosis imperative. Most patients complain of ischemic symptoms, though patients with aneurysmal disease occasionally experience symptoms related to…
In 1908, Takayasu, a Japanese ophthalmologist, reported retinal arteriovenous shunts in a wreathlike distribution around the optic disc and microaneurysms of the retinal vessels in a 19-year-old Japanese woman. In an ensuing discussion, Onishi related similar findings in a patient with pulseless, cool upper extremities. The etiology of the described ocular and vascular findings was at that time obscure but has since become known as Takayasu…
With the expanded application of the radiation therapy of malignancies has come the increased recognition of radiation-induced arteritis. Because ensuing vascular complications often develop insidiously, presenting as chronic ischemic syndromes, the role of earlier radiation is often overlooked. Radiation-associated arteriopathy is often misconstrued to be the more widely prevalent arteriosclerosis. Both are diseases of the elderly and are seen most often in technologically advanced societies, arteriosclerosis…
Carotid body tumors are the most common form of paraganglioma in the head and neck. These tumors are difficult to resect because of impressive vascularity, arterial adherence, and local cranial nerve involvement. Stroke and cranial nerve dysfunction remain sobering risks of surgical resection. However, advances in diagnostic imaging and surgical technique have reduced perioperative complications to a reassuringly low level. The carotid body is located in…
Extracranial carotid artery aneurysms represent an important but uncommon disease. Certain of these aneurysms are associated with thromboembolic complications causing stroke. Rupture of an aneurysm, especially in the case of a false aneurysm following carotid artery endarterectomy, represents a surgical emergency. Clinical manifestations and treatment vary, depending upon the type, size, and location of the aneurysm, warranting individual discussion of true aneurysms, traumatic false aneurysms, and…
The arterial blood supply to the upper extremities and brain is based on the supra-aortic trunk vessels, which include the innominate, left common carotid, and left subclavian arteries. The innominate artery is unique in that it is solely responsible for the circulation to the right arm and entire right hemisphere of the brain. Although a variety of pathologic disease processes are known to affect the innominate…
In the past, subclavian revascularization was most often performed to relieve either vertebrobasilar symptoms or exertional arm pain associated with subclavian steal syndrome. Currently, subclavian revascularization is increasingly undertaken to extend the proximal landing zone during endovascular management of thoracic aortic conditions including aneurysm, dissection, and trauma. Additionally, subclavian revascularization may be appropriate to maintain or restore normal inflow to the mammary artery used in coronary…
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The prevalence of atherosclerotic stenotic disease involving the proximal brachiocephalic arteries is significantly less than that in the extracranial carotid arteries. Additionally, only 10% of patients with hemodynamically significant proximal subclavian artery stenoses develop symptoms. This probably reflects the robust collateral network distal to ostial subclavian artery stenosis, including the vertebral and internal mammary arteries. Unfortunately, there is a paucity of data on the natural history…
Vertebrobasilar ischemia (VBI) is a syndrome with different etiologies. The term insufficiency, which is still commonly used, should be abandoned because it implies only a low-flow condition affecting the vertebrobasilar territory and ignores the important mechanism of microembolization that constitutes approximately a third of the VBI pathology. Low-flow VBI is more often than not caused by a drop in systemic blood pressure, but it can also…
Treatment of carotid fibromuscular dysplasia (FMD) in the past has been open graduated rigid carotid dilatation for symptomatic stenoses or segmental resection with saphenous vein interposition for aneurysms. The results of contemporary open surgical reports have shown the risk of stroke to be 1.4% to 2.8% and that of transient ischemic attack (TIA) to be 1.4% to 7.7%. Because high surgical exposure up to the first…
Most patients with carotid artery fibrodysplasia are likely to be asymptomatic, although the number reported without symptoms is small because most reported series are surgical experiences encompassing more advanced disease. Complications of this disease include embolization, dissections, and rupture with formation of an arteriovenous fistula. The most catastrophic clinical complication is stroke, and prophylactic interventions in asymptomatic patients are directed at reducing or eliminating this sequela…
Multiple indications exist for constructing an extracranial–intracranial (EC-IC) bypass. The indications that are encountered most frequently in contemporary practice are symptomatic occlusion of the internal carotid artery (ICA), stenosis or occlusion of the intracranial vasculature, usually at the level of the carotid siphon or middle cerebral artery (MCA), and intracranial aneurysms that are not amenable to endovascular treatment or to open ligation. Patients with an ipsilateral…