Thoracic Outlet Surgery for 16-year-old with Acutely Ischemic Hand After Embolization from Subclavian Artery Aneurysm
A right-handed, 16-year-old competitive tennis player was transferred urgently from another hospital’s ER with worsening pain and weakness of his right hand. Patient noted the onset of symptoms six weeks prior to evaluation with acute onset of pain in the hand and arm after a workout session. Despite physical therapy directed at ulnar nerve compression, he started to have diminished motor and sensory function of his hand. He was evaluated at another hospital’s ER for worsening pain and found to have a pulsatile mass in the right supraclavicular fossa with a cool, pulseless hand. Sensation was diminished and grip strength and dexterity were severely affected.
Diagnostic FindingsAn angiogram, CT angiogram and chest X-ray were performed.
• CT angiogram found a 20 x 22 mm subclavian artery aneurysm with luminal thrombus.
• CXR found presence of well-developed right-sided cervical rib.
• Angiogram found large subclavian aneurysm. Extensive embolization to the axillary and brachial arteries. Loss of the radial and ulnar arteries with only interosseous artery supplying hand. Embolization to distal radial and ulnar arteries with minimal reconstitution to hand.
Patient was diagnosed with thoracic outlet syndrome (TOS), arterial variant.
• Admitted and placed on therapeutic heparin prior to formal diagnostic angiogram.
• Definitive operation performed via a cervical approach. Cervical and first rib resection with resection of the aneurysm (see image below) and reconstruction of the subclavian artery using reversed greater saphenous vein. Extensive embolectomy and patch angioplasty of the axillary, brachial, ulnar, radial and interosseous arteries was performed. Large amounts of organized thrombus and embolic material were removed.
• Full anticoagulation with heparin and then Coumadin continued for three months postoperatively.
Immediate increase in strength and sensation. At three months, full use of hand and arm with ultrasound indicating completely normal-appearing vessels and normal wave forms with normal digital pressures. Playing competitive tennis five months post op.
• Thoracic outlet syndrome is very common among young and working-age patients. The arterial variant accounts for less than 1 percent of all cases but entails a far greater risk of limb loss secondary to acute arterial occlusion.
• Use of dedicated digital subtraction imaging performed in the hybrid room, along with advanced reconstructed three-dimensional imaging for operative planning, is essential for optimal outcomes with expedited operative therapy.
Scott R. Golarz, MD, FACS
Assistant Professor of Clinical Surgery, Lewis Katz School of Medicine at Temple University