Case Study: Chapter 05

Chapter 5: Subclavian, Upper Extremity, and Extracranial Vertebral Artery Disease

TIMOTHY WU, MD; RABIH A. CHAER, MD

CASE STUDY:

A 20-year-old, right-hand dominant man presented to the emergency department with a history of right-hand numbness, tingling, and poorly healing wounds of the digits for the last 6 months. He stated that this has somewhat worsened over the last 24 hours, prompting him to come to the emergency department for evaluation. Of note, he was given the diagnosis of a carpal tunnel syndrome several months ago, when these symptoms first began. He is currently doing well in college, which he attends on a swimming scholarship.

On examination his right arm was warm, and there was sluggish capillary refill of the digits at greater than 3 seconds. There were multiple, small nonhealing ulcerations of the first through third digits that appeared to be chronic. They were dry, without evidence of discharge or cellulitis. There was no exposure of deep tissues. He was neurologically intact. There was a prominent pulse over the right supraclavicular area, with no pulses at the brachial, radial, or ulnar levels distally. A pencil Doppler used at the bedside revealed a weak signal at the ulnar artery and the superficial palmar arch. There was also a weak signal noted at each digital artery. The left arm was completely normal on examination, with palpable pulses at all levels.

A digital-brachial index (DBI) was measured. The DBI on the right was 0.33. On the left, it was greater than 1.0 on rest.

A computed tomography angiogram (CTA) was obtained. This demonstrated a right subclavian artery aneurysm measuring 2 cm with extensive mural thrombus, with occlusion of the axillary and proximal brachial arteries.

Case Study: Chapter 5

* 1.) What is the most likely diagnosis in this patient?
* 2.) The patient was brought to the angiography suite, where a catheter was placed into the innominate artery to perform a right-arm runoff arteriogram.

This showed a brachial artery occlusion with reconstitution of the distal ulnar artery in the distal forearm. The radial artery is occluded. Catheter-directed arterial thrombolysis was begun. At 12 hours, there was no improvement in the arteriogram or his clinical symptoms. What should be the next step in management?

* 3.) The patient is scheduled for a right subclavian aneurysm repair and a bypass to the ulnar artery using a saphenous vein graft. What else should be performed at the time of operation for this patient with thoracic outlet syndrome?