“In aTOS where proximal arterial reconstruction is being considered detailed run off imaging should be performed before surgery”

“In aTOS where distal run off has been significantly compromised by trash consideration should be given to TO decompression alone with arterial reconstruction reserved for limb threatening ischaemia”

“In acute vTOS the interval between endovenous thrombectomy/lysis and decompression should be as short as is practicable. Where possible the use of a hybrid theatre can allow for synchronous endovenous thrombectomy and decompression” 

“In acute vTOs the optimal window for benefit for initiating thrombectomy/lysis and decompression is two weeks. Beyond this the majority opinion is that uncertain outcomes do not outweigh the risk of treatment. However, this so not preclude attempt in selected cases” 

“Major open reconstruction of chronically occluded subclavian veins associated with TOS is not recommended due to the risks of morbidity associated with the surgery” 

“nTOS can present after acute vTOS. This is thought to be either due to inflammation associated with thrombosis or due to new collateral formation. If decompression for acute vTOS has been decided against, then a period of observation for a few months is recommended to allow for inflammation to settle and for collaterals to mature which may improve symptoms.” 

“Scalene block is a valuable tool for both aiding diagnosis of nTOS and treatment. The use of LA, steroid and botox all have use in reducing irritation of the brachial plexus. It is thought that prolonged symptom relief can be explained by the knock-on effect of reducing inflammation of the trunks following interscalene block.”

"It was not thought that scalene block could predict the extent of decompression needed."

“There was no consensus on the extent of decompression that should be undertaken for nTOS. If no clear cause of impingement is identified decompression should include the first rib.”

“Neurophysiology is useful in excluding other causes of symptoms. It can also positively identify nTOS in advanced disease with established nerve damage. Progressive features on neurophysiology in long standing NTOS predict poor outcomes from non-operative management and guarded outcomes from operative management where the goal should be to prevent progressive worsening with some symptom relief (but not complete).”

“Nerve conductions studies should be performed on all patients before redo TOS surgery”

“Weight loss advice should be part of initial conservative management. This does not include muscular patients where BMI is not reliable. Muscular patients can be counselled to modify exercise patterns to high repetitions low weight to aid being lean and defined rather than low rep high weight to aid in adding muscle bulk which should be avoided.”

“Evidence for periop medical treatments to reduce nerve pain and recurrent symptoms is lacking. Anecdotal use of oral steroid, pregabalin, duloxetine and topical capsaicin have been used by members of the group with success”

"Small breaches in the pleura at time of TOS decompression can be adequately managed with a suction (Redivac) drain. Loss of vacuum should prompt CXR to exclude parenchymal injury and persistent pneumothorax needing chest drain."

"Tinel’s sign localised to the brachial plexus over the TO is a reliable sign in the diagnosis of nTOS. It indicates irritation of the brachial plexus consistent with nTOS."

"Aberrant arterial anatomy branching from the subclavian and intersecting the brachial plexus (i.e. transverse cervical artery) may be responsible for nTOS and should be ligated and divided."

"Breast reduction surgery should be considered in nTOS as an alternative to TO decompression following physiotherapy"

"Plain film (ideally thoracic inlet views) is a useful diagnostic test for all forms of TOS, is preferable to standard chest radiographs and is not superseded by cross sectional imaging."

"Paediatric TOS is a highly specialised service. Conservative management should not be pursued at the expense of definitive management in a specialist centre."

"Catheter venography is the preferred diagnostic test for chronic vTOS. The diagnostic accuracy of the test can be enhanced by the presence of the treating clinician and by placing the patient in a range of provocation positions. Enhanced flow through collateral vessels may indicate a tight localised stenosis that is not obvious on the imaging of the vein."

TBC