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Evidence on thoracic outlet syndrome comes mainly from expert consensus and from surgical series. There are no large trials comparing treatments, and the three forms of TOS each have their own, separate evidence.

QuestionMain sourcesWhat they show
How is neurogenic TOS defined and diagnosed?SVS reporting standards; INTOS consensusCombined clinical criteria, with history and examination at the center
How is it treated?INTOS consensus and case scenariosConservative care first for many; surgical practice varies
How is venous TOS treated?Venous review and surgical seriesPhased clot treatment and decompression
How is arterial TOS treated?Arterial seriesDecompression with repair of the artery
What does PURED achieve?Dr. Aghayev's series and anatomical studyPatient-rated improvement in all 61 patients, no permanent complications

Neurogenic TOS: definition and expert practice

The Society for Vascular Surgery's 2016 reporting standards defined neurogenic TOS by three of four criteria, including the response to an injection into the scalene muscle1. The 2024 INTOS consensus of specialist hand and nerve surgeons modified these criteria, dropping the injection, and placed history and examination at the center of diagnosis. It supports conservative care for many patients and records where surgeons disagree, including whether the first rib should always be removed2. A 2026 INTOS study of case scenarios found that experts proposed different plans for the same patients3.

Clinical guides and warning signs

The Society for Vascular Surgery publishes a perioperative guide for clinicians4, and the Vascular Society of Great Britain and Ireland a set of consensus statements on the vascular forms5. The NHS6 and the Society for Vascular Surgery7 describe the warning signs of a clot or a blocked artery that need urgent care.

Venous and arterial TOS

A 2024 review describes the phases of treatment for venous TOS with a clot, from clot treatment to decompression8, and a 2024 surgical series reports vein patency, symptoms, bleeding and repeat procedures separately9. A 2023 series describes arterial TOS, its complications and the need for repeat procedures10.

PURED

Dr. Kamran Aghayev, who edits Thoracic Outlet Syndrome Wiki, developed the PURED posterior approach. His 2023 series reports 80 operations in 61 patients with neurogenic TOS over an average of just over three years, with improvement rated excellent by 55 patients and good by 6, and no permanent complications11. An earlier report described his first nine patients12, and a cadaver study described the muscle-sparing route13. Like most TOS surgical evidence, these are single-surgeon series without a comparison group.

Recurrent TOS and long-term results

A 2022 study examined recurrent neurogenic TOS and the role of residual rib and scar tissue14. A long-term cohort found no association between the length of rib left after surgery and the outcome15.

References

  1. Illig KA et al. J Vasc Surg. 2016;64:e23–e35. doi:10.1016/j.jvs.2016.04.039. PubMed ↩
  2. Chim H, Hagan RR. Plast Reconstr Surg Glob Open. 2024;12:e6107. doi:10.1097/GOX.0000000000006107. Source ↩
  3. Chim H; INTOS Workgroup. J Hand Surg Am. 2026;51:982.e1–982.e9. doi:10.1016/j.jhsa.2026.03.014. PubMed ↩
  4. Society for Vascular Surgery. Thoracic Outlet Syndrome, Perioperative Management Guide. Source ↩
  5. Vascular Society of Great Britain and Ireland. Thoracic Outlet Syndrome Clinical Interest Group. Source ↩
  6. NHS. Thoracic outlet syndrome. Reviewed 14 December 2023. Source ↩
  7. Society for Vascular Surgery. Acute Limb Ischemia. Source ↩
  8. Davies MG, Hart JP. Front Surg. 2024;11:1302568. doi:10.3389/fsurg.2024.1302568. Source ↩
  9. Mota L et al. J Vasc Surg Venous Lymphat Disord. 2024;12:101959. doi:10.1016/j.jvsv.2024.101959. Source ↩
  10. de Kleijn RJCMF et al. Front Surg. 2023;9:1072536. doi:10.3389/fsurg.2022.1072536. Source ↩
  11. Aghayev K. World Neurosurg. 2023;180:e739–e748. doi:10.1016/j.wneu.2023.10.017. PubMed ↩
  12. Aghayev K, Ciklatekerlio O. Posterior upper rib excision for neurogenic thoracic outlet syndrome: feasibility and early outcomes. Oper Neurosurg. 2018;14(5):532-537. doi:10.1093/ons/opx143 PubMed ↩
  13. Akaslan I, Ertas A, Uzel M, Ozdol C, Aghayev K. Surgical anatomy of the posterior intermuscular approach to the brachial plexus. Hand (N Y). 2021;16(6):759-764. doi:10.1177/1558944719895619 PubMed ↩
  14. Jammeh ML et al. Hand (N Y). 2022;17:1055–1064. doi:10.1177/1558944720988079. PubMed ↩
  15. Nuutinen H et al. Interact Cardiovasc Thorac Surg. 2021;33:734–740. doi:10.1093/icvts/ivab172. PubMed ↩