Working Diagnosis:
Arterial Thoracic Outlet Syndrome with distal microemboli of the 3-5th digits

Treatment:
Given the patient's distal emboli, he was started on 3 months of anticoagulation with Lovenox and held from all pitching duties. He later required surgical repair outside of the system which was reported as revascularization without the need for first rib resection or scalenectomy.

Outcome:
After the patient's vascular surgery, he was unfortunately transferred from the organization and lost to subsequent medical follow-up. He did stay in some contact with the athletic trainer. He remained out of pitching activity for 6 weeks following surgery and then underwent a rehabilitation program over the off-season. He ultimately made a complete recovery and was pitching again by the next season. He went on to advance to his major league debut two seasons later.

Author's Comments:
Thoracic outlet syndrome can involve any portion of the neurovascular bundle passing through the shoulder. Any athlete engaged in high volume repetitive upper extremity motions is at risk for thoracic outlet syndrome, but given the mechanism of pitching, these athletes are at even increased risk. Of the three types of thoracic outlet syndrome, Neurogenic causes make up the vast majority (~90%) whereas most of those remaining cases are venous in origin. Arterial thoracic outlet syndrome accounts for 1-3% of all cases. The distinguishing factors of arterial thoracic outlet syndrome versus the other subtypes are pain localized mostly to the hand instead of the neck or upper arm which is particularly exacerbated with provocative exercise; coolness/pallor with diminished pulses; and early fatigue. In symptomatic patients, few non-surgical options exist, and treatment often involves arterial resection, revascularization or scalenectomy versus first rib resection.
Given the intermittent and repeated occlusion of the arterial supply and the subsequent turbulent flow and intermittent stasis, emboli often form distal to the occlusion. Digital arterial occlusion, as was evidenced by this patient's pain and coldness initiating in the third digit, can occur in the throwing hands of pitchers. Besides treating the possible underlying cause of thrombosis such as arterial thoracic outlet syndrome in this case, when evidence of embolization is present, patients require anticoagulation for 3 months in accordance with typical provoked DVT recommendations.

Editor's Comments:
A truly fascinating case given the rarity of this type of Thoracic Outlet Syndrome - arterial, accounting for only about 1% of all TOS. It is interesting to note that diagnostic techniques and criteria are still being developed and accurate and timely diagnosis is necessary to reduce morbidities.

There is evidence that in aTOS thrombolysis may be an operative option before surgical repair with possible conduit and thoracic outlet decompression. Some other morbidities associated with aTOS include repeated episodes of ischemia and limb-loss and/or compartment syndrome, which need to be immediately addressed.

The clinical data shows upper extremity ischemia due to emboli tends to have a poorer prognosis versus upper extremity ischemia not due to emboli. Most systematic reviews showed great improvement in primary outcomes after surgery.

Particularly interesting in this case is the distal ischemia and the lack of bone resection as this is usually required in aTOS. Potentially the research does not capture professional athletes and, perhaps, this was taken into consideration during the player’s surgical consultation.

References:
1. Cormier JM, Amrane M, Ward A, Laurian C, Gigou F. Arterial complications of the thoracic outlet syndrome: fifty-five operative cases. J Vasc Surg. 1989 Jun;9(6):778-87.

2. Daniels, Brian MD1; Michaud, Leslie MD2; Sease, Franklin Jr MD1,3; Cassas, Kyle J. MD, FACSM3; Gray, Bruce H. DO4. Arterial Thoracic Outlet Syndrome. Current Sports Medicine Reports: March/April 2014 - Volume 13 - Issue 2 - p 75-80.

3. Peek J, Vos CG, Ünlü Ç, van de Pavoordt HDWM, van den Akker PJ, de Vries JPM. Outcome of Surgical Treatment for Thoracic Outlet Syndrome: Systematic Review and Meta-Analysis. Ann Vasc Surg. 2017 Apr;40:303-326. doi: 10.1016/j.avsg.2016.07.065. Epub 2016 Sep 22.

4. Marine L, Valdes F, Mertens R, Kramer A, Bergoeing M, Urbina J. Arterial thoracic outlet syndrome: a 32-year experience. Ann Vasc Surg. 2013 Nov;27(8):1007-13. doi: 10.1016/j.avsg.2013.06.001. Epub 2013 Aug 22.

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