Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet
M. R. Nehler, L. M. Taylor Jr, G. L. Moneta and J. M. Porter
Department of Surgery, Oregon Health Sciences University, Portland, USA.
OBJECTIVE: To describe our experience with surgical therapy for upper
extremity ischemia incident to emboli from aneurysms of the subclavian
artery. DESIGN: Retrospective review case series. SETTING: Vascular surgery
practice at a university hospital-based tertiary referral center. PATIENTS:
All patients treated for upper extremity ischemia caused by embolism from a
subclavian artery aneurysm from January 1, 1990, to July 31, 1996.
INTERVENTION: All patients underwent detailed history and physical
examination, screening for immunologic and hypercoaguable disorders,
noninvasive vascular laboratory evaluation, and arteriography of the aortic
arch in both arms and hands. Surgical treatment consisted of rib excision
or fracture plating, aneurysm excision, and interposition vein grafting,
with additional saphenous vein bypasses to brachial or forearm arteries as
needed to provide uninterrupted circulation to the wrist. RESULTS: Twelve
patients (6 males; mean age, 37 years) were treated. All had episodic upper
extremity ischemia with an initial misdiagnosis of primary vasospastic
disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of
symptoms before correct diagnosis averaged 7 months (range, 1-36 months).
All patients had bony abnormalities of the thoracic outlet (8 cervical
ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All
aneurysms contained intraluminal thrombus, and all patients had multiple
ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating
chronic and repeated embolization. All patients underwent aneurysm excision
and interposition vein grafting, with additional vein bypass to the
brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up
was 18 months (range, 2 weeks to 63 months). Eleven patients had complete
symptomatic relief, and 1 patient improved. All subclavian interposition
grafts remained patient. Two distal bypass grafts occluded in patients with
preoperative arteriograms demonstrating no patient forearm arteries. There
has been no limb loss. CONCLUSIONS: Hand ischemia caused by embolization
from a subclavian artery aneurysm occurs in young patients without
atherosclerosis and is frequently misdiagnosed as vasospasm. Despite
advanced disease and multiple chronic distal arterial occlusions, surgical
treatment by resection of bony abnormalities, aneurysm excision and
grafting, and distal bypass grafting produces excellent results.
