Observational Study Medicine ®

Comparison of duplex ultrasound and

hemodynamic assessment with computed
tomography angiography in patients with arterial
thoracic outlet syndrome
Talal A. Altuwaijri, MDa,*

Abstract
Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely
on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality
for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-
intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify
the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS
who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial
pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity,
specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with
CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity,
specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For
arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with
duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%,
respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone.
The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS
could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.
Abbreviations: CTA = computed tomography angiography, HDA = hemodynamic assessment, MRA = magnetic resonance
angiography, NPV = negative predictive value, SCA = subclavian artery, SCV = subclavian vein, TOS = thoracic outlet syndrome.
Keywords: arterial hemodynamic assessment, computed tomography angiography, duplex ultrasound, thoracic outlet syndrome

1. Introduction traumatic events such as whiplash or a fall, or functional fac-

The term thoracic outlet syndrome (TOS) was first used by
Peet and colleagues in 1956 to describe a spectrum of condi-
tions resulting from compression of the neurovascular bun-
dle exiting the thoracic outlet.[1,2] Compression of the brachial
plexus, subclavian artery (SCA), or subclavian vein (SCV)
results in neurogenic, arterial, or venous TOS, respectively.[3]
Neurogenic TOS is the most common form and constitutes
over 95% of all TOS cases; venous TOS is found in 2 to 3% of
TOS patients; and arterial TOS is a less common form found in
<1% of all TOS patients.[4] TOS is also more commonly diag-
nosed in females, and patients are usually aged 20 to 50 years
at diagnosis.[5]
The underlying causes of TOS can be multifactorial and
may be related to congenital factors such as a cervical rib,
tors such as repetitive use injury in athletes and musicians.[6]
TOS is characterized by the presence of distinct symptoms,
including upper-extremity pallor, paresthesia, weakness, mus-
cle atrophy, and pain.[7] Although TOS is suspected on the
basis of clinical examination, the scope for differential diag-
nosis is wide, necessitating accurate diagnostic evaluation.
Direct imaging techniques are often used to elucidate the
underlying location and structure of compression. However,
such diagnostic testing methods often yield equivocal or neg-
ative findings in cases of neurogenic TOS due to the lack of
apparent or radiologically identifiable structural causes, mak-
ing neurogenic TOS a diagnosis of exclusion.[8,9] Assessment
for vascular TOS more often results in direct identification
of stenosis or occlusion of the SCA or SCV.[10–12] The stan-
dards for reporting vascular TOS proposed by the Society for

The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request.
a
Department of Surgery, College of Medicine, King Saud University, Riyadh,
Kingdom of Saudi Arabia.
*Correspondence: Talal A. Altuwaijri, Department of Surgery,
College of Medicine, King Saud University, P.O. Box: 7805 (37),
Riyadh 11472, Kingdom of Saudi Arabia (e-mail: taltuwaijri@ksu.edu.sa).
Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.
How to cite this article: Altuwaijri TA. Comparison of duplex ultrasound
and hemodynamic assessment with computed tomography
angiography in patients with arterial thoracic outlet syndrome. Medicine
2022;101:36(e30360).
Received: 2 December 2021 / Received in final form: 19 July 2022 / Accepted:
20 July 2022
ORCID: https://orcid.org/0000-0002-0833-2945http://dx.doi.org/10.1097/
MD.0000000000030360

1
Altuwaijri • Medicine (2022) 101:36Medicine
Vascular Surgery indicate that imaging results should be con-
sidered for the diagnosis of either arterial or venous TOS.[13,14]
In either case, early diagnosis is critical for timely interven-
tion, since long-term compression can result in disability and
permanent structural defects.
Several modalities are frequently utilized for diagnosis of
patients who exhibit symptoms of TOS, including plain radi-
ography, nerve-conduction studies/electromyography, ultraso-
nography, computed tomography angiography (CTA), dynamic
CTA, magnetic resonance angiography (MRA), and digital
subtraction angiography.[8,13] Plain chest radiography is the
most useful technique for an initial assessment and to identify
or rule out bony anatomical abnormalities or defects, such as
the presence of a cervical rib, first-rib anomalies, fracture cal-
luses, congenital osseous malformations, and focal bone lesions
that may compress the thoracic outlet.[15] Electrophysiological
tests, such as nerve-conduction studies or electromyography can
help establish a diagnosis of neurogenic TOS.[8] Newer imag-
ing techniques, such as MR neurography and diffusion tensor
imaging, are also emerging as useful diagnostic tools for neu-
rogenic TOS. MR neurography facilitates non-invasive visual-
ization of nerve morphology and signaling in peripheral nerves,
while diffusion tensor imaging assesses central nervous system
abnormalities.[16,17]
For vascular TOS, duplex ultrasound is typically the initial
imaging test. CTA and MRA can provide anatomical details in
unclear cases,[18] while digital subtraction angiography allows
accurate evaluation of the vasculature around the thoracic out-
let. However, digital subtraction angiography is invasive and
associated with the risk of contrast toxicity[19]; therefore, it is
usually performed when therapeutic intervention is planned.
The American College of Radiology Appropriateness Criteria
state that CTA and MRA are appropriate tools for diagnosis
of vascular TOS.[14] CTA provides superior analysis of the vas-
cular anatomy with respect to other structures, for example,
the course of the nerves cannot directly be seen on a CT scan
and has to be inferred from other surrounding structures.[20] In
contrast, MRA is more effective for the assessment of soft tis-
sue structures, particularly the presence of accessory muscles
(scalenus minimus, subclavius posticus, duplicated omohyoid
inferior belly, or pectoralis minimus muscle), muscle hypertro-
phy (omohyoid inferior belly, pectoralis minor, scalene, or sub-
clavius), and fibrous bands.[18,20,21] To this end, CTA and MRA
can be performed concomitant with postural maneuvers to facil-
itate diagnosis in patients with dynamically acquired compres-
sion.[7,20,22–24] However, MRA cannot always distinguish between
physiological and pathological compression of vascular struc-
tures. Additionally, MRA results do not always correlate with
patient symptoms and are associated with a high false-positive
rate of venous compression in asymptomatic populations.[25,26]
Encouraging results from CTA have identified this imaging
modality as the most appropriate technique for identification of
arterial or venous TOS, as evidenced by the correlation between
significant SCA stenosis on dynamic CTA and thoracic outlet
symptomatology.[27]
Although the field of imaging-based diagnostics is rapidly
evolving, these diagnostic imaging tests remain resource-inten-
sive. CTA is costly, resource-intensive, and not available in all
settings. Additionally, the technique is associated with radiation
exposure and contrast-related risks. Finally, CTA evaluations
only include the patient’s anatomy, precluding dynamic and
functional assessments of blood flow through the thoracic out-
let. Thus, other less invasive and more readily available diagnos-
tic techniques may be useful to rule out a diagnosis of arterial
TOS or strengthen the need for further diagnostic assessment.
Duplex ultrasound is a readily available and frequently
employed technique in cases of suspected vascular TOS, and
this imaging modality is considered an excellent initial assess-
ment tool. Duplex ultrasound is often used for assessment
of the presence of thrombosis, compression, stenosis, and
2
aneurysmal changes with remarkably high sensitivity and
specificity.[28,29] However, this technique is operator-dependent,
requires experience, and challenged by patient’s body habitus,
and even healthy individuals may show a certain degree of
arterial compression during the exaggerated positions com-
monly employed in ultrasound testing, with almost 30% of
the healthy population demonstrating significant changes in
Doppler waveforms in stress positions when compared with
those in a neutral position.[30] Hemodynamic assessment is
also useful since arterial TOS can cause significant differences
(>20 mm Hg) in arterial blood-pressure readings between both
arms or during stress-position assessments,[8] and identifica-
tion of these differences can bolster the evidence for arterial
TOS. However, since arterial TOS does not necessarily cause
pressure differences in some cases, the rate of false-results
in arterial TOS diagnoses using this method requires further
evaluation; nevertheless, both duplex ultrasound and hemo-
dynamic assessments are readily available, non-invasive, safe,
and relatively inexpensive.
Considering the limitations and challenges inherent in the
adjuvant imaging modalities currently used for diagnosis of
arterial TOS and the challenges in identifying the index tests
with the highest diagnostic accuracy,[26] a better understanding
of the utility of the more readily available diagnostic methods
and their combinations for accurate assessment of arterial TOS
is important to ensure timely diagnosis. Thus, the accuracy of
duplex ultrasound and Doppler arterial HDA alone or in com-
bination was compared with the accuracy of CTA in suggesting
the diagnosis of arterial TOS.
2. Methods
2.1. Patients
Data from patients with symptoms suggestive of arterial TOS
(claudication, hand pain, pallor, coldness, paresthesia, and/or
digital ischemia) at King Saud University Medical City between
2009 and 2018 were reviewed. Duplex ultrasound assessment
of blood flow in the SCA and SCV, arm arterial HDA, and con-
trast-enhanced helical CTA were performed for each patient.
The tests were performed on the left and right upper limbs
for each patient. The study was approved by the institutional
review board for Health Sciences Colleges Research on Human
Subjects, King Saud University College of Medicine (approval
number: E-21-5911). The need for informed consent was waived
due to the retrospective nature of the study.
2.2. Duplex ultrasound imaging
Duplex ultrasound imaging to examine the blood flow through
the arteries and veins was performed using an ultrasound
Phillips Epic 7-Color Doppler (Philips Medical Systems, Best,
Netherlands), a 12-5-MHz linear transducer, and an 8-5-MHz
curved transducer. The instrument utilized a constant angle of
60°, sample volume size of 1.5 mm, DR-56, wall filter of 60 Hz,
and frame rate on medium mode. These ultrasound scans were
performed with the patient in a sitting position in B-mode and
pulsed wave Doppler with the 12-5-MHz linear transducer and
8-5-MHz curved transducer.
Duplex ultrasound evaluations were performed with the
patient’s head rotated toward the contralateral side and the
arms in a neutral position. In this position, the proximal SCA
was examined anteriorly via the supraclavicular region, and the
distal portion of the SCA was examined via the infraclavicular
region. Subsequently, the ultrasound examination was repeated
with the arm in a hyperabduction stress position (180°). The
SCA was examined for thrombosis, stenosis, aneurysm, and
post-stenotic dilatation. In addition, the artery diameter and
peak systolic velocities were recorded, and the waveform was
Altuwaijri • Medicine (2022) 101:36www.md-journal.com
analyzed. The findings obtained on both sides were compared.
The SCV was similarly examined for evidence of thrombosis.
The duplex ultrasound scan suggested a diagnosis of arterial
TOS if there is a presence of an aneurysm, thrombus, symptomatic
positional compression, stenosis, or post-stenotic dilatation was
identified. During the stress position scan, a reduction of more
than 2 mm or 30% in the SCA diameter was considered suggestive
of arterial TOS. Additionally, a 2-fold increase in the peak systolic
velocity from the neutral position, flow reduction/occlusion, or the
presence of SCV thrombosis also suggested the diagnosis of arte-
rial or venous TOS. Additionally, a difference of more than 20%
in the peak systolic velocity between both upper limbs indicated a
higher possibility of a positive arterial TOS finding.
2.3. Arterial HDA
Arm arterial HDAs were performed using calibrated instru-
ments. Pulse-volume recordings and Doppler arterial pressure
measurements were conducted using the Nicolet Vasoguard
Pressure machine (VIASYS Healthcare, Conshohocken, PA)
with a 7.5-MHz transducer. The pressure-cuff size was 10 cm
for arm measurements. Bilateral upper-limb brachial artery
pressure was measured in patients in the neutral position by
using the pulse waveform. An initial difference of more than
20 mm Hg between both sides was suggestive of arterial TOS.
These measurements were then acquired in a hyperabduction
stress position (180°) with the head rotated to the contralateral
side. The pressure recording and the waveform were noted. A
drop of more than 20 mm Hg in the brachial artery pressure
(especially with flattening of the waveform amplitude) suggested
a positive diagnosis of arterial TOS.
2.4. Computed tomography
Contrast-enhanced helical CT was performed using a 64-row mul-
tidetector CT scanner (LightSpeed VCT; GE Healthcare, Chicago,
IL) with a slice thickness of 0.625 mm, pitch of 1.375, and field of
view of 50 cm. These scans included both shoulders and yielded
images encompassing the C6 level to the mid-chest region. A total
of 120 mL (60 mL per position) of iodinated non-ionic contrast
material was utilized. Iodixanol iodine (320 mg/mL) was injected
in the lower limb vein at a flow rate of 4 mL/s, and the scan timing
after injection was based on a preliminary test bolus.
CTA was performed with the patient in a neutral position
(arms at sides) and in a dynamic stress position (arms hyper-
abducted to 180° and in external rotation). The images were
evaluated for the degree of arterial compression at the thoracic
outlet following the hyperabduction stress maneuver in com-
parison with the arterial dimensions in the neutral position.
The degree of stenosis was determined according to the SCA
diameter reduction. A diameter reduction of more than 2 mm or
30% was considered suggestive of arterial TOS. In addition, the
Table 1
Positive and negative results of the different diagnostic tests.
Test
Duplex ultrasound (n = 49)
Significant change in size >2 mm or 30%
Significant change in PSV (2× increase or flow reduction/occlusion)
Change in arm arterial pressure (>20 mm Hg) (n = 45)
CTA scan (n = 49)
CTA = computed tomography angiography, PSV = peak systolic velocity.
3
presence of notation of stenosis, aneurysmal changes, thrombus,
or post-stenotic dilatation was considered suggestive of arterial
TOS; the presence of SCV thrombosis suggested the presence of
venous TOS.
2.5. Statistical analysis
All analyses were performed using IBM SPSS Statistics for
Windows, Version 26 (Chicago, IL). CTA scan results were used
as a reference; that is, positive CTA scan results were indica-
tive of a true-positive result and negative CTA scan results were
indicative of a true-negative finding. Duplex ultrasound and
arterial HDA results were considered false-positive if the val-
ues indicated a positive result while the CTA scan result was
negative. A false-negative result was indicated when the test
results were negative while the CTA scan result was positive.
On the basis of these measurements, the sensitivity, specificity,
negative predictive value (NPV), positive predictive value, and
false-negative rate were calculated. Missing data were treated
with multiple imputation under the missing-at-random assump-
tion. McNemar’s test was performed to compare the sensitiv-
ity and specificity of different investigation modalities, and all
reported P values were 2-tailed. The cutoff P value was 05.
Cochran’s formula was used for sample-size calculation based
on a confidence level of 95%, ±5% precision, and the incidence
of arterial TOS. Lastly, the distribution of continuous variables
was assessed using D’Agostino’s K-squared test. Variables that
followed a normal distribution were assessed using paramet-
ric tests, whereas non-normally distributed data were assessed
using non-parametric tests.
3. Results
A total of 49 patients were enrolled. The patients’ mean age
was 30.8 ± 13.8 (range 6–65) years, and 35 (71.4%) patients
were female. The resultant dataset included the 98 limbs of
49 patients who underwent duplex ultrasound and CTA. Arm
arterial HDA was performed in 45 patients (86 limbs). Table 1
shows the frequencies and percentages of positive and nega-
tive results for each of the test categories and their respective
subcategories.
On the basis of these results, aggregate scores for each of the
test categories (duplex ultrasound, arm arterial HDA, and CTA)
were computed (Fig. 1). For these scores, a positive result for any
of the subcategories indicated a general positive result for the
test. The duplex ultrasound test yielded 53 positive limb results,
while CTA indicated only 19 positive results. Furthermore, arm
arterial HDA showed 26 positive results.
After computing these aggregate scores, the sensitivity, spec-
ificity, positive predictive value, and NPV were computed by
comparing the result of each vascular laboratory test and their
combination with the CTA scan results. Therefore, the results
Subcategory Positive, n (%) Negative, n (%)
Thrombosis 0 (0) 98 (100)
Stenosis 15 (15.3) 83 (84.7)
Aneurysm 1 (1) 97 (99)
11 (15.3) 61 (84.7)
46 (52.9) 41 (47.1)
26 (30.2) 60 (69.8)
Thrombosis 1 (1) 97 (99)
Stenosis 6 (6.1) 92 (93.9)
Aneurysm 9 (9.2) 89 (90.8)
Change in size 14 (17.1) 68 (82.9)
Altuwaijri • Medicine (2022) 101:36Medicine
Figure 1. Number of positive and negative results for limbs tested for arterial thoracic outlet syndrome with computed tomography angiography, duplex
ultrasound, and arm arterial hemodynamic assessment. CTA = computed tomography angiography, HAD = hemodynamic assessment, TOS = thoracic outlet
syndrome.
of the duplex ultrasound and arm arterial HDA as well as
their combination in comparison with CTA were considered
(Table 2). A total of 86 limbs were assessed by all 3 tests and
were included in the analysis.
The combination of duplex ultrasound and arm arterial HDA
exhibited better sensitivity and NPV than either test alone. The
area under the curve for the combination was 0.74, suggesting
that this combined approach had acceptable discriminative pre-
diction ability (Fig. 2). Although no significant differences were
identified in terms of sensitivity, the specificity of the combined
approach was significantly lower than those of the 2 tests indi-
vidually. Moreover, the specificity of arm arterial HDA showed
higher statistical significance than the specificities of duplex
ultrasound alone or the combination of duplex ultrasound and
arm arterial HDA (Table 3).
Finally, the test results for limbs that showed positive results
on CTA (n = 19) were assessed. Of these, 19 limbs underwent
duplex ultrasound, while only 15 underwent arm arterial HDA.
The combination of duplex ultrasound and arm arterial HDA
exhibited the highest sensitivity of 93.3% (Fig. 3). Furthermore,
the combination of duplex ultrasound and arm arterial HDA
showed a lower false-negative rate than the results of either of
the 2 tests individually (Table 4).
As regards limbs showing positive results for arterial TOS
on vascular lab studies and/or CT angiography with no other
test (e.g., Raynaud’s tests, MRI) suggestive of another diag-
nosis (e.g., Raynaud’s Phenomenon, neurogenic TOS), surgical
supraclavicular decompression was performed for 15 limbs
Table 2
Sensitivity, specificity, PPV, and NPV for duplex ultrasound, arm arterial HDA, and their combination in comparison with CTA.
Test/combination TP, n TN, n FP, n
Duplex ultrasound 13 35 36
Arm arterial HDA 11 56 15
Duplex ultrasound + arm arterial HDA 14 30 41
CTA = computed tomography angiography, FN = false-negative, FP = false-positive, HDA = hemodynamic assessment, NPV = negative predictive value, PPV = positive predictive value, TN = true-negative,
TP = true-positive.
4
with surgical findings suggestive of SCA compression and sur-
gical decompression, including scalenectomy and cervical rib
or first rib resection. Follow-up showed clinical improvement.
4. Discussion
The combination of duplex ultrasound and arm arterial HDA
results showed a higher sensitivity and NPV than either test
alone and was most successful in identifying true-positive cases
in comparison with the CTA results. This analysis indicates that
duplex ultrasound may be used in combination with arm arte-
rial HDA to reliably rule out the need for CTA in patients with
symptoms of arterial TOS. Although no differences in sensitiv-
ity were observed among duplex ultrasound, arm arterial HDA,
and their combination, the specificity of arm arterial HDA was
the highest, and the specificity of the combined approach was
significantly lower than that of each individual test.
Although the diagnosis of arterial TOS is initially based on
clinical findings, imaging studies are required to eliminate the
possibility of other conditions with similar presentations and to
specify the site and etiology of the compression, its grade, and
any predisposing anatomical factors. While CTA is often the
investigation of choice for such diagnoses, it is not as safe and
convenient as HDA and duplex ultrasound since CTA exposes
patients to radiation and potential contrast toxicity and is more
expensive.
This analysis of patients who showed positive findings sug-
gestive of arterial TOS on CTA revealed that the combination
FN, n Sensitivity, % Specificity, % PPV, % NPV, %
2 86.7 49.3 26.5 94.6
4 73.3 78.9 42.3 93.3
1 93.3 42.3 25.5 96.8
Altuwaijri • Medicine (2022) 101:36www.md-journal.com

Table 4
Sensitivity and FNR for duplex ultrasound and arm arterial HDA
of limbs showing a positive CTA result for arterial TOS (n = 19).
Test/combination TP, n FN, n Sensitivity, % FNR, %

Duplex ultrasound 16 3 84.2 15.8

(n = 19)
Arm arterial HDA 11 4 73.3 26.7
(n = 15)
Duplex ultrasound + arm 14 1 93.3 6.7
arterial HDA (n = 15)
CTA = computed tomography angiography, FN = false-negative, FNR = false-negative rate,
HDA = hemodynamic assessment, TOS = thoracic outlet syndrome, TP = true-positive.

of duplex ultrasound and arm arterial HDA was the most sensi-
tive (93.3%) and yielded a lower false-negative rate than either
of the 2 tests individually, although the differences were not
statistically significant. The frequencies of true-positive (14 of
15) and false-negative (1 of 15) cases as well as the sensitiv-
Figure 2. Receiver operating characteristic (ROC) curve for duplex ultra- ity (93.3%) and false-negative rate (6.7%) of the combined
sound with arm arterial hemodynamic assessment score versus computed approach support our conclusion that this combination may
tomography angiography. be a preferable investigational line for the evaluation of the
presence of arterial TOS in suspected cases. This combination
of tests is particularly warranted in cases where CTA is not
Table 3 available or for screening cases that require further investiga-
Comparison of the sensitivity and specificity of different tion by CTA.
diagnostic techniques by using McNemar’s test. Duplex ultrasound is considered an excellent initial imaging
test for the diagnosis of suspected vascular TOS, and its use is
P value for the P value for the supported in the reporting standards issued by the Society for
Test/combination difference in sensitivity difference in specificity Vascular Surgery.[13,14] Duplex ultrasound also has the advantage
Duplex ultrasound vs .317 <.001 of allowing assessments of dynamic blood flow.[21] Additionally,
arm arterial HDA a recent report indicated that identification of compression of
Duplex ultrasound vs .317 .025 the SCV or SCA via duplex ultrasonography can also facili-
duplex ultrasound tate the diagnosis of neurogenic TOS,[31] further supporting the
+ arm arterial HDA use of this imaging modality. However, the high false-positive
Arm arterial HDA vs .083 <.001 rates obtained in duplex ultrasound dynamic analysis indicate
duplex ultrasound the need for updated ultrasound diagnostic protocols.[30] On
+ arm arterial HDA the other hand, significant (>20 mm Hg) differences in arterial
pressure during stress positioning can also support the diagno-
HDA = hemodynamic assessment. sis of arterial TOS, and this relatively quick and simple method

Figure 3. Sensitivity and negative predictive value for each test and their combination in comparison with computed tomography angiography results (n = 86).
HAD = hemodynamic assessment, NPV = negative predictive value, TOS = thoracic outlet syndrome.

5
Altuwaijri • Medicine (2022) 101:36Medicine
for assessment can provide weight to a suspected diagnosis. The
effectiveness of the combination of these 2 non-invasive methods
in comparison with CTA is particularly clinically relevant due to
the possible established reliability of this combination and their
safety and relatively lower cost in comparison with CTA.
This study had several limitations. First, the study was retro-
spective in nature; it only included 49 patients (98 limbs) and
only recruited patients from a single tertiary center. Nevertheless,
this study demonstrates that the combination of duplex ultra-
sound with arm arterial HDA could be utilized to determine the
need for further evaluation by CTA in patients with suspected
arterial TOS. Duplex ultrasound and arm arterial HDA are rel-
atively simple and readily available investigative modalities that
warrant further investigation though prospective, controlled
studies with larger sample sizes.
In conclusion, this study demonstrated that the combination
of duplex ultrasound and arm arterial HDA may be useful as a
screening examination to warrant the need for further confir-
matory CTA in cases of suspected arterial TOS. These methods
and their combination proved to be sensitive, suggesting that the
use of the safe, readily available, relatively inexpensive, non-in-
vasive, and reliable duplex ultrasound and arm arterial HDA
should be further examined for their relevance in the assessment
of patients who present with symptoms suggestive of arterial
TOS.
Acknowledgments
Dr. Hussam Anas, MD – Data collection; and Ms. Małgorzata
Jakubowska, PhD – Statistical analysis.
Author contributions
Conceptualization: Talal A. Altuwaijri.
Data curation: Talal A. Altuwaijri.
Formal analysis: Talal A. Altuwaijri.
Methodology: Talal A. Altuwaijri.
Project administration: Talal A. Altuwaijri.
Validation: Talal A. Altuwaijri.
Writing – original draft: Talal A. Altuwaijri.
Writing – review & editing: Talal A. Altuwaijri.
References
[1] Urschel HC Jr. The history of surgery for thoracic outlet syndrome.
Chest Surg Clin N Am. 2000;10:183–8, x.
[2] Atasoy E. History of thoracic outlet syndrome. Hand Clin. 2004;20:15–
6, v.
[3] Peet RM, Henriksen JD, Anderson TP, et al. Thoracic-outlet syndrome:
evaluation of a therapeutic exercise program. Proc Staff Meet Mayo
Clin. 1956;31:281–7.
[4] Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a
review. Neurologist. 2008;14:365–73.
[5] Juvonen T, Satta J, Laitala P, et al. Anomalies at the thoracic outlet are
frequent in the general population. Am J Surg. 1995;170:33–7.
[6] Atasoy E. Thoracic outlet compression syndrome. Orthop Clin North
Am. 1996;27:265–303.
[7] Demondion X, Herbinet P, Van Sint Jan S, et al. Imaging assessment of
thoracic outlet syndrome. RadioGraphics. 2006;26:1735–50.
[8] Jones MR, Prabhakar A, Viswanath O, et al. Thoracic outlet syndrome:
a comprehensive review of pathophysiology, diagnosis, and treatment.
Pain Ther. 2019;8:5–18.
[9] Citisli V. Assessment of diagnosis and treatment of thoracic outlet syn-
drome, an important reason of pain in upper extremity, based on liter-
ature. J Pain Relief. 2015;4:1–7.
[10] Maru S, Dosluoglu H, Dryjski M, et al. Thoracic outlet syndrome in
children and young adults. Eur J Vasc Endovasc Surg. 2009;38:560–4.
[11] Campbell WW, Landau ME. Controversial entrapment neuropathies.
Neurosurg Clin N Am. 2008;19:597–608, vi.
[12] Laulan J, Fouquet B, Rodaix C, et al. Thoracic outlet syndrome: defi-
nition, aetiological factors, diagnosis, management and occupational
impact. J Occup Rehabil. 2011;21:366–73.
[13] Illig KA, Donahue D, Duncan A, et al. Reporting standards of the
society for vascular surgery for thoracic outlet syndrome. J Vasc Surg.
2016;64:e23–35.
[14] Moriarty JM, Bandyk DF, Broderick DF, et al. ACR appropriateness
criteria imaging in the diagnosis of thoracic outlet syndrome. J Am Coll
Radiol. 2015;12:438–43.
[15] Zurkiya O, Ganguli S, Kalva SP, et al. ACR Appropriateness Criteria®
thoracic outlet syndrome. J Am Coll Radiol. 2020;17:S323–34.
[16] Magill ST, Brus-Ramer M, Weinstein PR, et al. Neurogenic thoracic
outlet syndrome: current diagnostic criteria and advances in MRI diag-
nostics. Neurosurg Focus. 2015;39:E7.
[17] Filler A. Magnetic resonance neurography and diffusion tensor imag-
ing: origins, history, and clinical impact of the first 50,000 cases with
an assessment of efficacy and utility in a prospective 5000-patient study
group. Neurosurgery. 2009;65(Suppl 4):A29–43.
[18] Baumer P, Kele H, Kretschmer T, et al. Thoracic outlet syndrome in 3T
MR neurography-fibrous bands causing discernible lesions of the lower
brachial plexus. Eur Radiol. 2014;24:756–61.
[19] Kuhn JE, Lebus GF, Bible JE. Thoracic outlet syndrome. J Am Acad
Orthop Surg. 2015;23:222–32.
[20] Khalilzadeh O, Glover M, Torriani M, et al. Imaging assessment of tho-
racic outlet syndrome. Thorac Surg Clin. 2021;31:19–25.
[21] Hussain MA, Aljabri B, Al-Omran M. Vascular thoracic outlet syn-
drome. Semin Thorac Cardiovasc Surg. 2016;28:151–7.
[22] Buller LT, Jose J, Baraga M, et al. Thoracic outlet syndrome: current
concepts, imaging features, and therapeutic strategies. Am J Orthop
(Belle Mead NJ). 2015;44:376–82.
[23] Hixson KM, Horris HB, McLeod TC, et al. The diagnostic accuracy of
clinical diagnostic tests for thoracic outlet syndrome. J Sport Rehabil.
2017;26:459–65.
[24] Povlsen S, Povlsen B. Diagnosing thoracic outlet syndrome: current
approaches and future directions. Diagnostics (Basel). 2018;8:21.
[25] Aralasmak A, Cevikol C, Karaali K, et al. MRI findings in thoracic
outlet syndrome. Skeletal Radiol. 2012;41:1365–74.
[26] Dessureault-Dober I, Bronchti G, Bussières A. Diagnostic accuracy of
clinical tests for neurogenic and vascular thoracic outlet syndrome: a
systematic review. J Manipulative Physiol Ther. 2018;41:789–99.
[27] Gillet R, Teixeira P, Meyer JB, et al. Dynamic CT angiography for the
diagnosis of patients with thoracic outlet syndrome: correlation with
patient symptoms. J Cardiovasc Comput Tomogr. 2018;12:158–65.
[28] Moore R, Lum YW. Venous thoracic outlet syndrome. Vasc Med.
2015;20:182–9.
[29] Butros SR, Liu R, Oliveira GR, et al. Venous compression syndromes:
clinical features, imaging findings and management. Br J Radiol.
2013;86:20130284.
[30] Bishop L, Bartlett M. Doppler waveform analysis during provocative
manoeuvres in the assessment for arterial thoracic outlet syndrome
results in high false-positive rates; a cross-sectional study. JRSM
Cardiovasc Dis. 2021;10:20480040211006571.
[31] Orlando MS, Likes KC, Mirza S, et al. Preoperative duplex scanning is
a helpful diagnostic tool in neurogenic thoracic outlet syndrome. Vasc
Endovasc Surg. 2016;50:29–32.