Arterial Thrombosis Complicating the Thoracic Outlet Syndrome: Arteriographic Considerations

Abstract

Thrombotic occlusion of the subclavian or axillary arteries, associated with the various thoracic-outlet-compression syndromes, is rare. The early recognition and correction of this arterial complication is most important because of the high incidence of severe secondary ischemic changes in the involved extremity. Precise arteriographic information as to the location and extent of these arterial lesions must be obtained prior to undertaking proper surgical management. Perusal of the literature discloses only a few reports dealing with this aspect of the subject (1–5). We have encountered 4 cases of subclavian-axillary artery thrombosis, 3 of which were associated with cervical rib and 1 with the scalenus anticus and hyper-abduction syndrome. One case has been previously reported (5) and will therefore not be discussed in this communication. Case Reports Case I: W. H., a 38-year-old white male, was admitted to Montefiore Hospital, New York, N. Y., with a four-month history of coldness, numbness, and increased fatigability of the left hand associated with diminished left radial and ulnar pulses. The diagnosis of scalenus anticus and hyperabduction syndrome was made, and a combined scalenotomy with tenotomy of the pectoralis minor muscle was performed. The patient was asymptomatic for approximately eighteen months and then began to notice a return of the previous symptoms. Physical examination now demonstrated rubor of the hand on dependency and marked blanching on elevation. The radial, ulnar, and brachial pulses were absent, while the axillary and subclavian pulses were easily palpable. A subclavian arteriogram (Fig. 1) demonstrated nonvisualization of the left brachial artery beyond the upper third of the humerus. Thoracic sympathectomy was subsequently performed with clinical improvement persisting to the present writing. Case II: E. C, a 52-year-old white woman, was admitted to Montefiore Hospital with a six-month history of extreme coldness of the right hand. There was associated pain in the fingers and hand as well as purplish discoloration of the fingers. Physical examination demonstrated an absent blood pressure in the right upper extremity while on the left it was 95/00. There was a small, painful ulcer about the nail of the fourth digit, and the right radial and brachial pulses were absent. The right hand was considerably colder than the left. Chest films disclosed bilateral cervical ribs. A right subclavian arteriogram demonstrated complete occlusion of the right midaxillary artery with minor collateral circulation about the shoulder, filling a small brachial artery segment (Fig. 2). A right scalenotomy was performed, resulting in increased warmth of the hand and healing of the digital ulcer. Case III: M. P., a 45-year-old white woman, was admitted to Montefiore Hospital with a sixmonth history of pain, paresthesia, weakness, and coldness of the right upper extremity.