Back to 2024 Abstracts
Staged Approach for Chronic Limb Threatening Ischemia in High-Performing Athlete with Arterial Thoracic Outlet Syndrome
Caroline E Minnick
1, Lindsay Lynch
2, Kevin Chang
2, Julie Freischlag
2, Matthew P Goldman
2 1Wake Forest University School of Medicine, Winston Salem, NC;
2Atrium Health Wake Forest Baptist, Winston Salem, NC
INTRODUCTION: Arterial thoracic outlet syndrome (aTOS) is the rarest form of thoracic outlet syndrome (TOS), accounting for 1-2% of cases. Cervical ribs or bony abnormalities, while rare in the general population, are present in most aTOS cases.METHODS:
A 21-year-old right-handed collegiate volleyball player presented to our outpatient vascular surgery clinic with non-healing ulcerations on the digits of her right hand. She reported two years of pain and paresthesia in her right upper extremity and had previously been diagnosed with Raynaud’s disease. She had then been sidelined from competition due to her pain and wounds.In the clinic, she had non-healing digital ulceration, absent radial pulses, decreased strength, and sluggish capillary refill in her right hand. She had a palpable axillary pulse with adduction of the right arm but absence of axillary pulse with abduction. Initial CT imaging from the referring institution (with right arm 180 degrees abducted) showed occlusion of the proximal axillary artery at the site of a large cervical rib with occlusion of the distal axillary and brachial arteries. She underwent bilateral upper extremity angiography with provocative maneuvers which showed patent bilateral axillary arteries with adduction and occlusion of the bilateral axillary arteries with abduction. The right brachial artery was occluded with distal reconstitution of the radial artery in the forearm. Subsequent CTA with adduction showed post-stenotic dilatation of the proximal axillary artery with no mural thrombus and multi-level occlusions of the runoff to the right hand.She underwent staged intervention beginning with a right trans-axillary cervical and first rib resection with scalenectomy. On post-operative day four she underwent right distal axillary to radial artery bypass (anatomic tunnel) with reversed saphenous vein graft. A palpable radial pulse was observed post-surgery, and she was discharged three days later.RESULTS:
At a three-week follow-up, the patient reported complete symptom resolution and healed digital ulcerations. Arterial duplex confirmed a patent bypass without stenosis. At three months post-operation, her condition remained stable, and anticoagulation was discontinued. Repeat CTA at 9 months post-operation demonstrated near-resolution in axillary artery dilation with widely patent bypass. She has returned to playing collegiate volleyball without issues.CONCLUSIONS:
In this case report we describe the management of aTOS in an overhead collegiate athlete that was complicated by distal embolization and tissue loss. We describe management via transaxillary rib resection with subsequent distal bypass with an excellent functional and anatomic outcome
Back to 2024 Abstracts
