Presentation
History of SLE. Presenting with absence of pulses in left upper extremity.
Patient Data
Scout image shown to demonstrate the position of the patient prior to obtaining the CT scan.
Vasculature:
The imaged segments of the aorta and its major branch vessels are patent, noting common origin of the right brachiocephalic artery and the left common carotid artery, as well as the left vertebral artery arising directly off the aortic arch. There is a short segment severe stenosis (axial, coronal, sagittal) at the junction of the left subclavian and axillary artery.
There is abrupt vessel cut off of the distal left brachial artery, concerning for occlusion without distal reconstitution. No contrast opacification is seen in the expected region of the radial or ulnar arteries or arteries of the hand.
Bones:
There is a left C7 cervical rib (scout, axial, sagittal) which demonstrates a pseudoarthrosis/bifid configuration with the left first rib.
Angiography of the left upper extremity at rest demonstrates patency of the left subclavian artery down to the brachial artery at the level of the elbow. The radial artery is occluded at its origin without distal perfusion.
Angiography of the left upper extremity during arm raise demonstrated a 3 cm segment of severe stenosis of the proximal subclavian artery at the level of the extranumery cervical rib.
Case Discussion
This is a case of arterial thoracic outlet syndrome (aTOS) seen on both CTA and left upper extremity angiography. On the catheter angiography study, images were obtained both at neutral (arm adducted) and abducted positions. On the abducted images, the severe stenosis can be seen, compatible with arterial thoracic outlet syndrome. Given the association, occlusion of the radial artery is thought to be secondary to the aTOS.
Following a left carotid subclavian bypass, the patient needed fasciotomies intraoperatively due to gangrene. Patient overall did well at a follow-up outpatient visit, with improved range of motion and decreased pain and edema.
CO-AUTHORS:
Alannah McCann
Bilal Arif, MD
Travis Bevington, MD
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