This Article  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in this journal  Topic Collections  • Surgery  • Surgical Interventions  • Vascular Surgery  • Alert me on articles by topic  Social Bookmarking   What's this?

Arch Surg. 2006;141:514.

Answer: Subclavian Artery Aneurysm Secondary to Cervical Rib
The surgical anatomy of the subclavian artery is routinely described in 3 distinct sections. The first or most proximal part of the artery extends to the medial border of the anterior scalene muscle. This portion of the artery gives rise to the internal mammary artery, vertebral artery, and thyrocervical trunk and is affected by thoracic outlet compressive syndromes only secondarily by retrograde propagation of thrombus. The second portion of the subclavian artery is retroscalene. This is often the site of stricture and positional compression and, when present, the proximal area of dilation or aneurysm formation. Finally, the third part of the subclavian artery extends from the lateral border of the anterior scalene to the lateral border of the first thoracic rib.¹

Although the first description of arterial complications secondary to anatomic variations in the thoracic outlet was published in The Lancet in 1861,² recognition that such vascular injuries were the consequence of repetitive motion and cumulative trauma did not come until recently.^3-4 Patients manifesting symptoms of arterial thoracic outlet syndrome are often young, healthy active individuals (manual laborers, athletes, etc), and, although not seen in all cases, anatomic variations such as cervical ribs, supernumerary scalene muscles, or persistent fibrocartilaginous bands often play an important role in these arterial compressive syndromes.^5-6

Patients with arterial compression syndromes of the thoracic outlet will often first present with unilateral cold hypersensitivity, Raynaud phenomenon, and/or edema of the hand. This is often initially misdiagnosed as collagen vascular disease. Fingertip pain, cold-induced ischemia, and punctate ulcers, usually at the paronychial area, can occur as the disease progresses. With complete occlusion of the axillosubclavian artery, patients may report easy fatigability in the affected limb and worsening of symptoms with exercise.

Diagnosis of arterial compression at the thoracic outlet requires arteriography in almost all cases. Both the degree of stenosis and aneurysmal dilation can be evaluated; however, this diagnostic modality can underestimate the luminal irregularities subsequently found at the time of operation (Figure 3). Prompt operative intervention is necessary in these patients to prevent complete arterial occlusion and/or obliteration of the outflow vessels to the hand by repeated embolization. The standard approach is decompression of the thoracic outlet with first thoracic rib removal and scalenectomy. Cervical ribs and fibrocartilaginous bands are also resected when present. Vascular reconstruction with either direct repair or interposition graft is required when there is complete occlusion, aneurysm, or poststenotic dilation. This patient underwent thoracic first rib resection, scalenectomy, cervical rib resection, and arterial reconstruction with reversed saphenous vein from the left lower extremity.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 3. Intraluminal ulceration in resected subclavian artery specimen.

Patients with symptoms consistent with arterial compression at the thoracic outlet should have their diagnosis confirmed promptly by arteriography before irreparable damage to the outflow vessels occurs. Surgery must consist of both decompression of the thoracic outlet and arterial reconstruction when significant dilation or intraluminal abnormalities are present. With aggressive management, patients can expect excellent clinical results and a return to normal physical activity.¹

AUTHOR INFORMATION

Jump to Section  • Top  • Answer: subclavian artery...  • Author information  • References

Correspondence: David J. Caparrelli, MD, Department of Surgery, The Johns Hopkins Medical Institutions, Blalock 618/600 N Wolfe St, Baltimore, MD 21287 (dcaparrelli{at}jhu.edu).

Accepted for Publication: May 2, 2005.

REFERENCES

Jump to Section  • Top  • Answer: subclavian artery...  • Author information  • References

1. Machleder HI. Arterial compression at the thoracic outlet. In: Machleder HI, ed. Vascular Disorders of the Upper Extremity. Armonk, NY: Futura Publishing Co Inc; 1998:197-225. 2. Coote H. Exostosis of the left transverse process of the seventh cervical vertebrae, surrounded by blood vessels and nerves, successful removal. Lancet. 1861;1:360-361. FULL TEXT 3. Cormier JM, Amrane M, Ward A, Laurian C, Gigou F. Arterial complications of the thoracic outlet syndrome: fifty-five operative cases. J Vasc Surg. 1989;9:778-787. PUBMED 4. Durham JR, Yao JS, Pearce WH, Nuber GM, McCarthy WJ III. Arterial injuries in the thoracic outlet syndrome. J Vasc Surg. 1995;21:57-70. FULL TEXT | WEB OF SCIENCE | PUBMED 5. Makhoul RG, Machleder HI. Developmental anomalies at the thoracic outlet: an analysis of 200 consecutive cases. J Vasc Surg. 1992;16:534-545. FULL TEXT | WEB OF SCIENCE | PUBMED 6. Nehler MR, Taylor LM Jr, Moneta GL, Porter JM. Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg. 1997;132:527-532. FREE FULL TEXT

SECTION EDITOR: GRACE S. ROZYCKI, MD

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

RELATED ARTICLE

Image of the Month—Quiz Case
David J. Caparrelli, Deborah M. Tabulov, and Julie A. Freischlag
Arch Surg. 2006;141(5):513.
EXTRACT | FULL TEXT