Thoracic Outlet Obstruction - Arterial Embolization

Thoracic Outlet Obstruction - Arterial Embolization

Antonios P. Gasparis, M.D.
John J. Ricotta, M.D.

Brief Case History

A 56-year-old female presented with acute right upper extremity ischemia.  Her past medical history was unremarkable except for a history of intermittent episodes of numbness and tingling in the hand for the past four months.  On examination, her hand was ischemic with absent brachial, radial, and ulnar pulses.  She had a pulsatile mass in the supra-clavicular area with a bruit.  Plain films of the cervical spine and chest revealed a cervical rib on the right side (Fig. 1). There were no neurologic deficits. The patient was anticoagulated and underwent a diagnostic angiogram, which revealed a subclavian aneurysm with occlusion of the brachial artery (Fig. 2). 

She underwent thrombolytic therapy with partial improvement (Fig. 3) and was, therefore, taken to the operating room.  Through supra- and infra-clavicular incisions, she underwent resection of the aneurysm, cervical rib, and first rib (Fig. 4).  Revascularization was achieved with an interposition PTFE graft (Fig. 5).  The brachial artery was subsequently exposed via an antecubital incision and was thrombectomized successfully, reestablishing a palpable radial pulse.