IMAGES
Critical Hand Ischemia Caused by True Arterial Thoracic Outlet Syndrome Ralph Yachoui, MD* and David E. Feinstein, DOÞ
A
previously healthy 44-year-old right-hand-dominant man presented to our institution with complaints of right hand pain, coolness, and blueness for the last 3 months. He worked as a mechanic with arms elevated. His cardiovascular risk factors included cigarette smoking, 1 pack daily for 30 years, and borderline hypertension. He had no history of Raynaud phenomenon. On physical examination, the right radial pulse was diminished, whereas sensitivity, muscle strength, and reflexes were normal. Patchy ischemic skin with unhealing ulcers of the tip of the third and fifth fingers was present (Fig. 1). Nailfold capillaroscopy was normal. A suspected diagnosis of vasculitis and hypercoagulable state was ruled out after careful history and physical and normal autoantibody testing. During the workup, the patient admitted having an old fracture of the right clavicle. This led to the tentative diagnosis of an arterial thoracic outlet syndrome (TOS). The diagnosis was confirmed by contrast-enhanced computed tomography showing compression of the right subclavian artery between an exuberant heterotopic clavicular bone formation and the first rib (Fig. 2). An upper-extremity angiogram demonstrated complete occlusion of the proximal ulnar and radial arteries just beyond the elbow consistent with probable emboli (Fig. 3). Anticoagulation therapy was initiated, and the patient subsequently underwent
FIGURE 1. Ischemic hand and right third fingertip and fifth fingertip ulcers. Color available online at www.jclinrheum.com.
FIGURE 2. Computed tomography angiography of the right upper limb shows occlusion of the subclavian artery (white arrow) between a heterotopic clavicle and the first rib (black arrows). Color available online at www.jclinrheum.com.
From the *Marshfield Clinic, Marshfield, WI; and †Department of Rheumatology, Cooper Medical School of Rowan University, Voorhees, NJ. The authors declare no conflict of interest. Correspondence: Ralph Yachoui, MD, Marshfield Clinic, 1000 N Oak Avenue, Marshfield, WI 54449. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 1076-1608/14/2001Y0054 DOI: 10.1097/RHU.0000000000000065
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surgical resection of the right clavicle and embolectomy of the right ulnar and radial arteries, resulting in very good inflow of arterial blood. Thoracic outlet syndrome is a well-known condition in adult patients; most of them (95%) present with neurologic symptoms. Thoracic outlet syndrome can be classified into 3 types: neurogenic, venous, and arterial TOS. True arterial TOS
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Hand Ischemia and Thoracic Outlet Syndrome
cervical ribs or scar tissue after clavicle fracture.2 It can lead to critical upper-limb ischemia probably from distal arterial embolization mimicking vasculitic, vasospastic, or obliterative processes.3 Without surgical treatment, the prognosis is poor with spontaneous development of gangrene.3 Clinicians should be aware of arterial TOS as a structural vascular cause of upper-limb critical ischemia.
REFERENCES FIGURE 3. Angiogram of the right upper-extremity shows complete occlusion of the proximal ulnar and radial arteries just beyond the elbow, consistent with probable emboli.
accounts for only 1% of all TOS cases.1 It is nearly always associated with a correctable anatomic bony abnormality such as
* 2013 Lippincott Williams & Wilkins
1. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007;46:601. 2. Davidovic LB, Kostic DM, Jakovljevic NS, et al. Vascular thoracic outlet syndrome. World J Surg. 2003;27:545Y550. 3. Garnier D, Chevalier J, Ducasse E, et al. Arterial complications of thoracic outlet syndrome and pseudarthrosis of the clavicle: three patients. J Mal Vasc. 2003;28:79Y84.
www.jclinrheum.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
55
Critical Hand Ischemia Caused by True Arterial Thoracic Outlet Syndrome Ralph Yachoui, MD* and David E. Feinstein, DOÞ
A
previously healthy 44-year-old right-hand-dominant man presented to our institution with complaints of right hand pain, coolness, and blueness for the last 3 months. He worked as a mechanic with arms elevated. His cardiovascular risk factors included cigarette smoking, 1 pack daily for 30 years, and borderline hypertension. He had no history of Raynaud phenomenon. On physical examination, the right radial pulse was diminished, whereas sensitivity, muscle strength, and reflexes were normal. Patchy ischemic skin with unhealing ulcers of the tip of the third and fifth fingers was present (Fig. 1). Nailfold capillaroscopy was normal. A suspected diagnosis of vasculitis and hypercoagulable state was ruled out after careful history and physical and normal autoantibody testing. During the workup, the patient admitted having an old fracture of the right clavicle. This led to the tentative diagnosis of an arterial thoracic outlet syndrome (TOS). The diagnosis was confirmed by contrast-enhanced computed tomography showing compression of the right subclavian artery between an exuberant heterotopic clavicular bone formation and the first rib (Fig. 2). An upper-extremity angiogram demonstrated complete occlusion of the proximal ulnar and radial arteries just beyond the elbow consistent with probable emboli (Fig. 3). Anticoagulation therapy was initiated, and the patient subsequently underwent
FIGURE 1. Ischemic hand and right third fingertip and fifth fingertip ulcers. Color available online at www.jclinrheum.com.
FIGURE 2. Computed tomography angiography of the right upper limb shows occlusion of the subclavian artery (white arrow) between a heterotopic clavicle and the first rib (black arrows). Color available online at www.jclinrheum.com.
From the *Marshfield Clinic, Marshfield, WI; and †Department of Rheumatology, Cooper Medical School of Rowan University, Voorhees, NJ. The authors declare no conflict of interest. Correspondence: Ralph Yachoui, MD, Marshfield Clinic, 1000 N Oak Avenue, Marshfield, WI 54449. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 1076-1608/14/2001Y0054 DOI: 10.1097/RHU.0000000000000065
54
www.jclinrheum.com
surgical resection of the right clavicle and embolectomy of the right ulnar and radial arteries, resulting in very good inflow of arterial blood. Thoracic outlet syndrome is a well-known condition in adult patients; most of them (95%) present with neurologic symptoms. Thoracic outlet syndrome can be classified into 3 types: neurogenic, venous, and arterial TOS. True arterial TOS
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology
&
Volume 20, Number 1, January 2014
Hand Ischemia and Thoracic Outlet Syndrome
cervical ribs or scar tissue after clavicle fracture.2 It can lead to critical upper-limb ischemia probably from distal arterial embolization mimicking vasculitic, vasospastic, or obliterative processes.3 Without surgical treatment, the prognosis is poor with spontaneous development of gangrene.3 Clinicians should be aware of arterial TOS as a structural vascular cause of upper-limb critical ischemia.
REFERENCES FIGURE 3. Angiogram of the right upper-extremity shows complete occlusion of the proximal ulnar and radial arteries just beyond the elbow, consistent with probable emboli.
accounts for only 1% of all TOS cases.1 It is nearly always associated with a correctable anatomic bony abnormality such as
* 2013 Lippincott Williams & Wilkins
1. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007;46:601. 2. Davidovic LB, Kostic DM, Jakovljevic NS, et al. Vascular thoracic outlet syndrome. World J Surg. 2003;27:545Y550. 3. Garnier D, Chevalier J, Ducasse E, et al. Arterial complications of thoracic outlet syndrome and pseudarthrosis of the clavicle: three patients. J Mal Vasc. 2003;28:79Y84.
www.jclinrheum.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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