Updated: 12/14/2019

Acute Subclavian Artery Thrombosis

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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
  • 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
  • Prognosis
    • outcomes with treatment
      • favorable prognosis has been reported with prompt recognition and treatment
    • outcomes without treatment
      • progression to stroke and upper extremity amputation
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
    • 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
 

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