Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet

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. Settings 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. Interventions: 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 patent. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patent 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.