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Updated: May 22 2021

Acute Subclavian Artery Thrombosis

  • Introduction
    • Acute upper extremity ischemia caused by a proximal occlusion at the level of the subclavian artery
  • Epidemiology
    • Incidence
      • rare 
        • <1% of population
    • Risk factors
      • aortic arch abnormality
      • aortic arch syndrome
      • trauma
      • arterial catheterization
      • pre-existing stenosis
  • Etiology
    • Pathophysiology
      • pathophysiology
        • limb pain occurs secondary to lack of blood flow to the extremity
      • pathoanatomy
        • unclear but may be secondary to nonocclusive proximal atherosclerotic plaque and/or cardiac embolization
  • Anatomy
    • Blood Supply
      • left
        • subclavian is the third branch off the aortic arch
      • right
        • subclavian is one of two branches of the brachiocephalic (innominate) artery
    • Biomechanics
      • subclavian supplies vertebral artery which join to form basilar artery to supply cerebellum
  • Presentation
    • History
      • sudden onset of symptoms without inciting event
      • Atrial fibrillation is associated in 80% of the cases of upper extremity thromboembolism
    • Symptoms
      • common symptoms
        • arm pain
        • nausea
        • severity
        • paresthesias
    • Physical exam
      • inspection
        • cyanotic/pale upper extremity
        • diffuse tenderness
        • cold limb
      • neurologic
        • a normal neurologic examination is common
      • neurovascular
        • pulses absent (axillary, brachial, radial, and ulnar)
        • doppler signals may be present in nonocclusive disease
      • provocative
        • different blood pressures may be noted on affected and unaffected upper extremity
        • increased pain and fatigue with upper extremity with the exertion of the limb
  • Imaging
    • Arteriography
      • recommended diagnostic modality
      • allows for percutaneous treatment of the occlusion
    • CT angiography
      • can be performed expeditiously to rule out other causes of occlusion
    • MRA
      • cannot treat occlusion at time of diagnosis
    • Doppler ultrasonography
    • Echocardiography
      • can rule out cardiac embolus following treatment of thrombosis
  • Studies
    • Labs
      • hypercoagulable panel be performed to rule out underlying disorder
      • labs often unremarkable
  • Treatment
    • Nonoperative
      • oral and IV anticoagulation
        • indications
          • limited role for nonoperative treatment with limb-threatening ischemia
          • intravenous and oral anticoagulation can be used to supplement percutaneous or surgical treatment
    • Operative
      • percutaneous treatment
        • indications
          • any patient with symptomatic limb ischemia
        • techniques
          • intra-arterial thrombolysis
          • percutaneous transluminal angioplasty (PTA)
          • manual aspiration
          • stenting
      • surgical treatment
        • indications
          • any patient with symptomatic limb ischemia
        • techniques
          • embolectomy/thrombectomy
          • bypass grafting
  • Complications
    • Limb ischemia
      • gangrene
      • loss of limb
    • Basilar stroke
      • delay in diagnosis
        • prolonged ischemia can progress to decreased cerebral perfusion and acute stroke symptoms
      • iatrogenic
        • if vertebro-basilar artery system is left unprotected during endovascular treatment embolism can occur
  • Prognosis
    • Outcomes with treatment
      • favorable prognosis has been reported with prompt recognition and treatment
    • Outcomes without treatment
      • progression to stroke and upper extremity amputation
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