Hybrid therapy for acute upper limb ischaemia with thoracic outlet syndrome: a case report

Arterial thoracic outlet syndrome (ATOS) is characterized by upper extremity ischaemia or aneurysm-like disease caused by external compression of the subclavian or axillary arteries at the thoracic outlet. Arterial thoracic outlet syndrome is the least common type of thoracic outlet syndrome (TOS), accounting for 1%–2% of all TOS cases. Acute limb ischaemia (ALI) is a life-threatening condition requiring urgent assessment and management. Although ALI most commonly affects the lower limb, 20% of cases involve the upper limb. The first-line treatment for ALI is surgical thrombectomy; however, some reports have found endovascular treatment to be effective.

A 45-year-old man complained of rest pain and paraesthesia in the left arm for the past week. Physical examination revealed coldness and pallor of the left upper limb and absence of the brachial pulse. Computed tomography revealed pseudarthrosis due to left cervical ribs, aneurysmal change of the left subclavian artery with thrombus, and distal occlusion beyond the brachial artery. Electrocardiography showed a normal sinus rhythm, and echocardiography showed no thrombus in the left ventricle. We diagnosed acute upper limb ischaemia due to subclavian artery aneurysms with TOS. He underwent emergent surgical thrombectomy via the left brachial artery. Surgical resection of the cervical and first rib was performed 1 month later, and endovascular treatment with a stent graft was performed for the aneurysmal change 3 months later.

We report a rare case of TOS with aneurysmal change and thrombosis. Arterial thoracic outlet syndrome should be considered in acute upper limb ischaemia when the embolic cause is unknown.