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Tools of Ignorance
02-27-2006, 12:23 PM
This is an interesting article on Kip Wells. Well, mostly interesting to me as I help treat this problem in children, and have an active research protocol on this problem.

Thoracic Outlet Syndrome is a series of symptoms caused by irritation as the "neurovascular bundle" leaves the chest to go out the arm. This includes the subclavian and axillary artery, subclavian, brachiocephalic and axillary veins, and the nerve. They get "pinched" when the tunnel they travel through (the Thoracic Outlet) is abnormally narrowed, and with high levels of stress. In athletes, the scalene muscle can get large and cause the pinching. In others, there can be an extra rib "cervical rib" that caused bony pinching. Any narrowing can be exascerbated by the overhead motion. I have treated baseball pitchers, volleyball players, weight lifters, and even someone who worked in a movie theatre concession where she had to lift her arm over her head to activate the soda machine!

Symptoms are usually due to arm swelling from vein blockage or clot. The vein is floppy, and the repetetive stress caused scarring and narrowing. When the blood doesn't flow well enough, a clot occurs and the arm swells. The scarring can just block off the whole vein as well without an actual clot.

Less common symptoms are injury to the artery (it is tougher and therefor usually stays open). David Cone had arterial injury.

Nerve symptoms are the least common, but include numbing and tingling. The nerve is the smallest in size, and least likely to be pinched.

Treatment is controversial. Blood flow will find its way around a clot or blocked vein. However, the swelling will remain for quite sometime. Therefore, we prefer to lyse the clot, and perform angioplasty of the vein to alleviate these symptoms. Others just say "screw it" as the veins can eventually close again anyway, and the symptoms are temporary (vein problem only). These patients need to be on blood thinner for 6 months to keep the vein open. Stents are contraindicated! The metal mesh will be crushed by the same narrowing that blocked the vein.

Surgery to open the narrowed area usually involves removing the top rib. As expected, this is pretty invasive, and will sideline someone for a while. However, the vein will just become blocked again if the surgery isn't done, and surgery is mandatory for those with arterial or nerve symptoms.



Associated Press




BRADENTON, Fla. -- Pittsburgh Pirates starter Kip Wells was examined Saturday by a St. Louis surgeon who specializes in blood clots.


Wells left the Pirates on Friday night and was checked by Dr. Robert Thompson, a vascular surgeon at Washington University, general manager Dave Littlefield said.


Littlefield called the move "a precautionary measure" and said he had no further details. Wells, who approached team officials Thursday to complain of arm fatigue, is expected to rejoin the team Sunday, Littlefield said.


Thompson has operated on two major league players, Colorado Rockies pitcher Aaron Cook in 2004 and Arizona Diamondbacks outfielder Luis Terrero in 2003. Each needed to have a rib removed and a vein redirected to remedy an affliction known as thoracic outlet syndrome, one in which a vein from the chest to the arm is constricted.


Cook returned to playing baseball in eight months, Terrero in five months.


The 28-year-old Wells is coming off a disappointing season in which he went 8-18 with a 5.09 earned run average. The Pirates signed him to a one-year, $4.15 million contract in January and avoided arbitration.