Presentation
This patient has been experiencing intermittent claudication of the left arm for many years.
Patient Data
There is a focal levoconvex scoliosis at the cervicothoracic junction, and an apparent left cervical rib.
During the arms up position, there is high-grade narrowing of the left subclavian artery, as it passes through a gap 2 mm wide between the left clavicle and the superiormost left rib. The first rib articulates with both the sternum and left second rib. There is however good contrast opacification in these subclavian artery and its branches distal to this point of external compression. There are no filling defects to suggest thrombus. On the right, the minimum distance between clavicle and first rib is 7 mm in the arms up position which equals the diameter of the right subclavian artery, and no compression is evident. Unremarkable aortic arch. Innominate and left common carotid artery appear normal.
Case Discussion
Subclavian vessel compression in the costoclavicular space accounts for less than 10% of cases with thoracic outlet syndrome. In this case, the subclavian artery compromise is due to a combination of a focal levoconvex scoliosis and an abnormal 1st/2nd rib complex.
Technical note: IV contrast administration should occur contralateral to the side under investigation; as in this case where injection was made via a cannula in the right antebubital fossa. Otherwise dense contrast medium within the subclavian vein will cause streak artefact in the region of interest.
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