The body’s vascular system runs from head to toe. When an artery or vein narrows with plaque and blocks blood flow, damage results to the heart, brain and lungs. Likewise a blood clot, aneurysm, or weakened or ruptured vein complicates healing and overall health. Within the St. Vincent Heart Center system, the vascular specialists provide medication therapies, non-surgical and surgical interventions as part of our Vascular Center of Excellence. We do more procedures in Indiana than other vascular providers and that experience translates into a patient benefit: expertise, access to new techniques and procedures that are generating better outcomes and an overall higher quality of care. There is a reason vascular disease (in particular carotid artery disease) is called the “Silent Killer”, because stroke can sneak up and when it does it’s a health crisis. For this reason our St. Vincent vascular team has developed high standards of care that start at the Emergency Room level and extend through outpatient and inpatient experiences.
The first step to vascular health is controlling cardiovascular risk factors. When that's not enough, St. Vincent has some of the most experienced vascular specialists in the country. Start your vascular care close to home at any St. Vincent hospital. If you need more advanced vascular care, you will have peace of mind that your physician will coordinate with specialists at our flagship location in Indianapolis: St. Vincent Heart Center.
Want to know more about your vascular health? Schedule a $79 TriVascular Screening.
Your vascular care team includes interdisciplinary experts, including vascular surgeons, interventional cardiologists and interventional radiologists who will recommend therapeutic and disease-management options. Our goal is to help you stay active and feel better when doing daily activities.
Vascular conditions can be difficult to diagnose - in fact, we suspect only 12 percent of people with peripheral vascular disease (PVD) receive an accurate diagnosis. And, unfortunately, many times the first sign of carotid artery disease is a stroke. If you have heart disease risk factors, regular visits with your physician can help detect a vascular condition.
Your doctor may recommend these or other imaging tests to help diagnose a vascular condition like PVD or carotid artery disease.
At St. Vincent, it is our primary standard of care to identify the least invasive and most effective procedures available for your individual condition. Treatment options vary from patient to patient, so our team will help you explore all the options, including:
Learn more about your risk for vascular conditions with a $79 TriVascular Screening. Or, visit one of our vascular specialists who can diagnose, treat and consult on the full range of vascular-related diseases and conditions. We often see patients with:
St. Vincent Heart Center has a high-volume, and growing, vascular surgery program. Our surgeons lead the way in minimally invasive and endovascular procedures, which are guided by cutting-edge imaging technology.
We emphasize a minimally invasive approach to vascular surgery whenever possible. For patients, benefits include:
At St. Vincent, Indianapolis, Vascular Surgeon George Sheng, MD, has created a multi-disciplinary approach to diagnosing and treating thoracic outlet syndrome (TOS) to significantly improve a patient’s quality of life. TOS is associated with nerve and blood vessel entrapment in the shoulder and arm. Dr. Sheng and colleagues diagnose TOS in adults and children who work extensively doing overhead tasks, including athletes in swimming, baseball, softball and volleyball. In many cases the pectoralis minor muscle is also injuried. This multi-disciplinary center includes a thorough evaluation and onsite diagnostic testing, a specialized physical therapy approach, trigger point injection program, botox injection and surgical interventions.
When left-sided shoulder pain is present, St. Vincent physicians always rule out heart disease and use nerve-conduction studies to rule out other causes of nerve pain in the neck and shoulder. Trigger point pain in the pectoralis minor muscle (radiating through the shoulder, pecs and shoulder blade) may occur secondarily to underlying heart disease and may be related to TOS. The TOS staff provides comprehensive follow-up care for all types of TOS including pectoralis minor syndrome.
Universally, this condition is caused by the compression of body structures (nerves and blood vessels) in the neck and upper chest area. Our vascular physicians are highly experienced in diagnosing and treating this often misdiagnosed condition.
Thoracic outlet syndrome (NTOS) and pectoralis minor syndrome (PMS) are the most common and presents with series of vague neurological symptoms, ranging from numbness and tingling in hands and fingers with activity -- to weakness and debilitating pain in shoulder, neck, and arm. To learn more about NTOS click here.
Venous thoracic outlet syndrome (VTOS) causes a blood clot to form in deep venous system in the affected arm. As result of the upper extremity deep venous thrombosis (DVT), a patient can have debilitating arm swelling and even a life-threatening pulmonary embolism. To learn more about VTOS click here.
Arterial thoracic outlet syndrome (ATOS) is an exceedingly rare form of TOS and is frequently associated with the presence of an extra rib (referred to the 1st rib or cervical rib) on the affected side. ATOS can be limb threatening due to aneurysm formation in the artery. To learn more about ATOS click here.
The St. Vincent Center for Treatment of Thoracic Outlet Syndrome attracts patients from throughout Indiana and the nation. Our staff has streamlined the patient experience so that during a 2-3 hour appointment all the necessary tests, a thorough evaluation, and a personalized treatment plan can be developed. Online consultations are also available to individuals seeking a second opinion. Please contact our office to schedule an appointment or consultation.
The least common form of Thoracic Outlet Syndrome. This condition threatens the arm and hand due to blockages in the artery that go to arm and hand. ATOS is typically related to the presence of an extra rib and repetitive use of that extremity.
Most patients with ATOS have a congenital cervical rib. This rib sits above the 1st rib and causes compression of subclavian artery (the artery that provides blood supply to arm and hand). With repetitive injury the artery can form aneurysm (abnormal dilation of the artery) that either shower clots to the hand or clots off completely. This condition, if not treated immediately, could lead to limb loss. The medical image below is from one of our patients. The arrow shows the location of aneurysm and extra rib.
The treatment of ATOS is immediate removal of the extra rib, removal of aneurysm, and restoration of blood flow to the hand.
This condition is the most common form of thoracic outlet syndrome. NTOS represents up to 90% of all TOS diagnoses. Most commonly, the patient will presents with vague upper extremity, shoulder, and neck symptoms.
Symptoms of Neurogenic Thoracic Outlet Syndrome
NTOS is caused by dynamic compression and irritation of nerves at the neck and shoulder level. Deep muscles in the neck anterior scalene muscle and 1st rib form a narrowed space through which the brachial plexus passes through (outlined in green on the illustration below). This is one site where nerve and blood vessel compression typically occurs.
Pectoralis Minor Syndrome (PMS) can present by itself in conjunction with NTOS. This condition is caused by compression of nerve fibers below the collarbone by a muscle called pectoralis minor muscle. Symptoms are similar to NTOS.
Physical therapy is the initial treatment option for NTOS. It is important to work with physical therapists that are familiar with this condition. We have teamed up with physical therapists and chiropractors throughout the country to establish a care system for these patients. With effective physical therapy, 60 to 70% of NTOS and PMS patients are cured without further treatment.
BOTOX® injection (a neuromuscular blocker) in the trigger points related to the shoulder and arm nerve compression site can be extremely effectively in managing the debilitating symptoms of NTOS and PMS. This procedure with insurance coverage is done as an outpatient in our facility. For more information about BOTOX see frequently asked questions.
Surgical decompression of the entrapped nerve is reserved for those that fail to respond to conservative treatments for NTOS and PMS. This procedure is performed through a small incision above the collarbone. Scalene muscle and first rib are removed to achieve the most effective decompression. Pectoralis minor muscle resection can be performed at the same time or independently. This procedure usually takes 1 to 2 hours and the patient will typically recover in the hospital for 1 to 2 days. These vascular surgeons are very experienced in these advanced surgical techniques. Annually the TOS surgical team performs approximately 40 to 50 procedures with outstanding results. (Since, no complications or adverse events have been reported).For more information about the NTOS surgical procedure, see frequently asked questions.
This condition is also known as Effort Thrombosis or Paget-Schroetter Syndrome. While venous thoracic outlet syndrome can coincide with NTOS, it often presents independently. VTOS often affects “overhead” athletes. Patient presents with classic findings of blood clots in subclavian and arm vein on affected side. Common symptoms are bluish color and swelling of arm and shoulder with pain.
VTOS is caused by chronic compression and subsequent scarring of subclavian vein between collarbone (clavicle) and 1st rib (see picture below with blue arrow). Repetitive use of upper extremity leads to scar formation around the vein that ultimately causes blood clot to form. Some patient also have undetected clotting disorders that put them at further risk for Venous Thoracic Outlet Syndrome.
VTOS is treated urgently with blood thinners. This prevents blood clot from going to lungs, also known as pulmonary embolism. Also the blood thinner keeps extension of clots to small veins in arm. The immediate treatment for VTOS is dissolving the clot using a catheter. This procedure is known as catheter directed thrombolysis. Once the blood clot is fully dissolved, surgical removal of 1st rib is usually recommended to prevent future development of blood clot and to open collapsed vein.
The overall outcome with treatment of VTOS is very good. Greater than 95% of the patients are able to resume normal use of their arms without any swelling. The rest of the patients may experience mild swelling with vigorous use of that arm. Majority of our patients are off the blood thinner within three months.
For additional information contact Dr. George Sheng, Vascular Surgeon, email George.Sheng@ascension.org or call the Center at 317-583-7600.
NTOS rarely causes permanent nerve damage; however, debilitating pain, numbness and tingling can cause significant life style limitations. This patient also tends to use the affected extremity less which may lead to muscle atrophy and impaired range of movement.
With a dedicated physical therapist who is familiar with this condition, 60% of our patients never required further therapy.
BOTOX works by relaxing muscles in neck and shoulder area, this allows
the pressure on nerves to decrease with time. Additionally, there is
increasing evidence that BOTOX can directly decrease nerve sensitivity
We offer a maximum of two treatment per site. BOTOX injection is especially useful in a selected group of “overhead” athletes (swimming, baseball, softball, and volleyball). When NTOS and/or PMS is related to repetitive use associated with sports only (a patient’s daily life is not significantly affected), we can often get these athletes through the season without surgery. Additionally, we also have good success with insurance coverage when it comes to BOTOX injection.
3 to 5 days to achieve maximal effect. It typically lasts 3 months minimally.
Minimal if any. We have performed more than 200 injections to date, and had no adverse effect in any patient.
If the diagnosis is established accurately by someone who is experienced
through trigger point injection and vascular studies, surgical
treatment has over 90% success rate. Surgery is only reserved for those
that have failed conservative management.
This depends on the patient. Pain control is the primary reason for
patients to stay in hospital. Patients usually stay in hospital
overnight up to 3 days. Most patients return to work in 2 to 4 weeks
with weight lifting restrictions. We start physical therapy within days
of discharge from hospital. Athletes may take up to 6 to 8 weeks before
reconditioning due to weight lifting restrictions.
Nerve injury, bleeding, lymphatic fluid leak and infection. These risks significantly decrease with a surgeon how has extensive experience surgically treating TOS. At the St.Vincent Center for Thoracic Outlet Syndrome, our surgical team performs 50 to 60 of these procedures a year and have had no complications to date.