Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome  Karl A. Illig, MD, Dean Donahue, MD, Audra Duncan, MD, Julie Freischlag, MD, Hugh Gelabert, MD, Kaj Johansen, MD, Sheldon Jordan, MD, Richard Sanders, MD, Robert Thompson, MD  Journal of Vascular Surgery  Volume 64, Issue 3, Pages e23-e35 (September 2016) DOI: 10.1016/j.jvs.2016.04.039 Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 1 An overall view of the right thoracic outlet, examined from in front of and to the right of the subject. The thoracic outlet area is made up of several distinct spaces. Nerve (yellow) compression can occur at the scalene triangle or pectoralis minor space, whereas venous compression most often occurs at the costoclavicular space. Arterial injury is most often due to bone trauma at the scalene triangle. (Modified from Sanders RJ, Haug CE. Thoracic outlet syndrome: a common sequela of neck injuries. Philadelphia: JB Lippincott; 1991. p. 34. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 2 Anterior view of the upper chest showing bilateral thoracic outlets, scalene triangles, and pectoralis minor spaces involved in compression of the brachial plexus. (Modified from Sanders RJ. Anatomy of the thoracic outlet and related structures. In: Illig KA, Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI, editors. Thoracic outlet syndrome. London: Springer-Verlag; 2013. p. 17-24. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 3 Detailed view of the scalene triangle on the patient's right side. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 4 Anatomy of the subclavian vein at the costoclavicular space. (Modified from Sanders RJ, Haug CE. Thoracic outlet syndrome: a common sequela of neck injuries. Philadelphia: JB Lippincott; 1991. p. 236. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 5 Arterial thoracic outlet syndrome (ATOS) and common bone abnormalities. A, Right side: An anomalous first rib inserting into the midportion of the right second rib. Note that there is no anterior portion of the right first rib to insert at the sternum as the normal left first rib is doing. Note too that the reason this is anomalous first rib is that it arises from the transverse process of T1. Left side: A cervical rib originating from the transverse process of C7. This is attaching to the midportion of the second rib by a congenital band. All incomplete cervical ribs attach to either the first or second rib by such a band. B, Cervical ribs may insert on either the first rib as shown on the left side or second rib as shown on the right side. On the right side, the first rib is absent, which can lead to calling the cervical rib an anomalous first rib. The only difference is point of origin from either C7 or T1. On the left side, the cervical rib is inserting into a normal first rib sandwiching the subclavian artery between the rigid cervical rib and a tight anterior scalene muscle. This causes stenosis and poststenotic dilation of the artery. (Modified from Sanders RJ. Anatomy and pathophysiology of ATOS. In: Illig KA, Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI, editors. Thoracic outlet syndrome. London: Springer-Verlag; 2013. p. 545-9. By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 6 Elevated arm stress test (EAST). This test is used to assess symptoms caused by narrowing of the scalene triangle. The “stress” refers to the fact that the arms are abducted 90 degrees, elbows bent, and brought backwards. The hands are usually briskly opened and closed for up to 3 minutes in this position, although this is not strictly necessary; a positive test result is represented by reproduction of local or distal pain and neurologic symptoms. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 7 Upper limb tension test (ULTT). This test is used to assess symptoms caused by stretch of the brachial plexus; the head is canted away from the side being tested (A and B). A positive test result is represented by reproduction of peripheral pain or neurologic symptoms (B); symptoms only with bending of the elbow (C) may indicate cubital tunnel syndrome. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 8 A two-axis descriptive tool for neurogenic thoracic outlet syndrome (NTOS). The x-axis represents the physician's suspicion that NTOS is present and is graded low, medium, or high. The y-axis is the patient's description of the impact the symptoms have on the quality of his or her life and is also graded low, medium, or high. Journal of Vascular Surgery 2016 64, e23-e35DOI: (10.1016/j.jvs.2016.04.039) Copyright © 2016 Society for Vascular Surgery Terms and Conditions