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Forearm Volume Changes Estimated by Photo-Plethysmography During an Original Candlestick/Prayer Maneuver in Patients With Suspected Thoracic Outlet Syndrome.

ABSTRACT: Objective: Hemodynamic investigations in thoracic outlet syndrome (TOS) remain difficult, even in trained hands. Results are generally reported as either presence or absence of venous compression. In fact, in patients with suspected TOS but without chronic venous occlusion, the forearm volume changes may result from various combinations of forearm position from heart level, arterial inflow, and/or venous outflow positional impairment. Design: Cross sectional, retrospective, single center study, accessible on Clinicaltrial.gov under reference NCT04376177. Material: We used venous photo-plethysmography (V-PPG) in 151 patients with suspected TOS. The subjects elevated their arms to the "candlestick" (Ca) position for 30 s and then kept their arm elevated in front of the body for an additional 15 s ("prayer" position; Pra). This CA-Pra procedure was repeated three times by each patient with recording of both arms. Method: We classified V-PPG recordings using an automatic clustering method. Result: The blinded clustering classification of 893 V-PPG recordings (13 missing files) resulted in four out of seven clusters, allowing the classification of more than 99% of the available recordings. Each cluster included 65.73, 6.16, 17.13, and 10.8% of the recordings, respectively. Conclusion: Venous hemodynamic profiles in TOS are not only either normal or abnormal. With V-PPG, four clusters were observed to be consistent with, and assumed to result from, the four possible associations of presence/absence of arterial inflow/venous outflow positional impairment: (1) normal response (maximal emptying in Ca and Pra), (2) isolated inflow impairment (emptying in Ca and filling in Pra due to post-ischemic vasodilation), (3) isolated venous outflow impairment (emptying then filling in Ca due to arterial inflow and emptying in Pra), and (4) simultaneous inflow/outflow impairment (emptying in Ca but no filling due to concomitant inflow impairment and further emptying in Pra).

SUBMITTER: Hersant J

PROVIDER: S-EPMC8076800 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Objective: Fingertip photoplethysmography (PPG) resulting from high-pass filtered raw PPG signal is often used to record arterial pulse changes in patients with suspected thoracic outlet syndrome (TOS). Results from venous (low-pass filtered raw signal) forearm PPG (V-PPG) during the Candlestick-Prayer (Ca + Pra) maneuver were recently classified into four different patterns in patients with suspected TOS, two of which are suggestive of the presence of outflow impairment. We aimed to test the effect of probe position (fingertip vs. forearm) and of red (R) vs. infrared (IR) light wavelength on V-PPG classification and compared pattern classifications with the results of ultrasound (US). Methods: In patients with suspected TOS, we routinely performed US imaging (US + being the presence of a positional compression) and Ca + Pra tests with forearm V-PPG IR . We recruited patients for a Ca + Pra maneuver with the simultaneous fingertip and forearm V-PPG R . The correlation of each V-PPG recording to each of the published pattern profiles was calculated. Each record was classified according to the patterns for which the coefficient of correlation was the highest. Cohen's kappa test was used to determine the reliability of classification among forearm V-PPG IR , fingertip V-PPG R , and forearm V-PPG R . Results: We obtained 40 measurements from 20 patients (40.2 ± 11.3 years old, 11 males). We found 13 limbs with US + results, while V-PPG suggested the presence of venous outflow impairment in 27 and 20 limbs with forearm V-PPG IR and forearm V-PPG R , respectively. Fingertip V-PPG R provided no patterns suggesting outflow impairment. Conclusion: We found more V-PPG patterns suggesting venous outflow impairment than US + results. Probe position is essential if aiming to perform upper-limb V-PPG during the Ca + Pra maneuver in patients with suspected TOS. V-PPG during the Ca + Pra maneuver is of low cost and easy and provides reliable, recordable, and objective evidence of forearm swelling. It should be performed on the forearm (close to the elbow) with either PPG R or PPG IR but not at the fingertip level.

Project description:UnlabelledThe authors' experience with the supraclavicular approach for the treatment of patients with primary thoracic outlet syndrome (TOS) and for patients with recurrent TOS or iatrogenic brachial plexus injury after prior transaxillary first rib resection is presented. The records of 33 patients (34 plexuses) with TOS who presented for evaluation and treatment were analyzed. Of these, 12 (35%) plexuses underwent surgical treatment, and 22 (65%) plexuses were managed non-operatively. The patients who were treated non-operatively and had an adequate follow-up (n = 11) were used as a control group. Of the 12 surgically treated patients, five patients underwent primary surgery; four patients had secondary surgery for recurrent TOS; and three patients had surgery for iatrogenic brachial plexus injury. All patients presented with severe pain, and most of them had neurologic symptoms. All nine (100%) patients who underwent primary surgery (n = 5) and secondary surgery for recurrent TOS (n = 4) demonstrated excellent or good results. On the other hand, six (54%) of the 11 patients from the control group had some benefit from the non-operative treatment. Reoperation in three patients with iatrogenic brachial plexus injury resulted in good result in one case and in fair results in two patients; however, all patients were pain-free. No complications were encountered. Supraclavicular exploration of the brachial plexus enables precise assessment of the contents of the thoracic inlet area. It allows for safe identification and release of all abnormal anatomical structures and complete first rib resection with minimal risk to neurovascular structures. Additionally, this approach allows for the appropriate nerve reconstruction in cases of prior transaxillary iatrogenic plexus injury.Electronic supplementary materialThe online version of this article (doi:10.1007/s11552-009-9253-0) contains supplementary material, which is available to authorized users.

Project description:Background: Exercise oximetry allows operator-independent recordings of microvascular blood flow impairments during exercise and can be used during upper arm provocative maneuvers. Objective: To study the test-retest reliability of upper-limb oximetry during the Roos test in patients with suspected thoracic outlet syndrome (TOS). Materials and Methods: Forty-two patients (28 men, 14 women; mean age: 40.8 years) were examined via transcutaneous oxygen pressure (TcpO2) recordings during two consecutive Roos tests in the standing position. The minimal decrease from rest of oxygen pressure (DROPmin) value was recorded after each maneuver was performed on both arms. The area under the receiver operating characteristic (ROC) curve defined the DROPmin diagnostic performance in the presence of symptoms during the tests. The Mann-Whitney U-test was used to compare the DROPmin in the symptomatic vs. asymptomatic arms. The test-retest reliability was analyzed with Bland-Altman representations. The results are presented as means ± standard deviations (SD) or medians [25-75 percentiles]. Results: The symptoms by history were different from the symptoms expressed during the Roos maneuvers in one-third of the patients. The DROPmin measurements were -19 [-36; -7] mmHg and -8 [-16; -5] mmHg in the symptomatic (n = 108) and asymptomatic (n = 60) arms, respectively. When TOS observed on ultrasound imaging was the endpoint, the area under the ROC curve (AUC) was 0.725 ± 0.058, with an optimal cutoff point of -15 mmHg. This value provided 67% sensitivity and 78% specificity for the presence TOS via ultrasound. When symptoms occurring during the test represented the endpoint, the AUC was 0.698 ± 0.04, with a cutoff point of -10 mmHg. This provided 62% sensitivity and 66% specificity for the presence of pain in the ipsilateral arm during the test. The test-retest reliability of DROPmin proved to be good but not perfect, partly because of unreliability of the provocation maneuvers. Conclusion: To the best of our knowledge, this study is the first to investigate microvascular responses during the Roos maneuver in patients with suspected TOS. The presence of symptoms was significantly associated with ischemia. TcpO2 facilitated the recording of both macrovascular and microvascular responses to the Roos test. The Roos maneuver should probably be performed at least twice in patients with suspected TOS.

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Forearm Volume Changes Estimated by Photo-Plethysmography During an Original Candlestick/Prayer Maneuver in Patients With Suspected Thoracic Outlet Syndrome.

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