Arterial thoracic outlet syndrome (TOS): diagnostic standards and surgical decompression

Arterial thoracic outlet syndrome (aTOS) requires differentiation from neurogenic and venous forms. Standardized diagnostic imaging includes dynamic duplex ultrasonography and computed tomography angiography (CTA) or magnetic resonance angiography (MRA) performed in both neutral position and with abduction/external rotation to document arterial compression, morphologic lesions such as post-stenotic dilatation or aneurysm, and thrombus. It is critical to distinguish pathological compression from physiological variants, as positional arterial compression can be observed in up to 20% of asymptomatic individuals; thus, a diagnosis of aTOS typically requires evidence of structural arterial damage or distal complications [@dengler2022]. Indications for surgical intervention include documented arterial compression with aneurysm or thrombus formation, or recurrent ischemia with distal embolization. The surgical approach consists of first rib or cervical rib resection combined with scalenectomy, which forms the cornerstone of treatment for arterial TOS.aTOS. When aneurysm or focal intimal disease is present, concomitant arterial reconstruction is performed using endarterectomy, patch angioplasty, or interposition vein grafting. Isolated stenting across the thoracic outlet without decompression is not recommended due to persistent external compression and the risk of stent fracture. Evaluation and management of distal embolization with thrombectomy or catheter-directed thrombolysis should be performed as clinically indicated. [@demondion2006] [@over1998] [@dengler2022]