Provocative Maneuvers

The patient, sitting straight, takes a deep breath and holds it. This maneuver tightens the anterior middle scalene muscles resulting in possible decrease in the radial pulse. Unfortunately, it is a very frequent finding in normal individuals.

Fig 22.1. Anatomic relationships at the thoracic outlet.

Fig 22.2 a. Left subclavian arteriogram in a patient with thoracic outlet syndrome with the arm abducted and externally rotated demonstrating complete occlusion of the subclavian artery with reconstitution of the axillary artery by extensive collaterals.

Fig 22.2b. Left subclavian arteriogram in another patient with the arm adducted demonstrating significant post-stenotic dilation of the subclavian artery.

Fig 22.2c.When the arm is abducted and externally rotated, an obstruction to the sub-clavian artery is seen. Further abduction of the arm resulted in complete occlusion at this level. Both these patients had a rudimentary first rib with an abnormal exosto-sis between the first and second ribs. This was the cause of the compression to the subclavian artery. Transaxillary resection of the first and second ribs was curative in both cases.

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