Working Diagnosis:
Subclavian Artery Aneurysm Secondary to Arterial Thoracic Outlet Syndrome from a Cervical Rib

Treatment:
The patient underwent surgical decompression with scalenectomy and resection of his left cervical rib. They decided intraoperatively to not remove his first thoracic rib Case Photo #6 , Case Photo #7 , Case Photo #8 .

Outcome:
Following surgical resection of his cervical rib and scalenectomy, he was initially held from sports participation for 6-8 weeks. He was then able to slowly return to sport and able to participate in his collegiate indoor track and field championships.

Author's Comments:
Thoracic outlet syndrome (TOS) affects approximately 2% of the population and arises from compression of the neurovascular structures in the thoracic outlet, either at the scalene triangle, the costoclavicular space, or the subcoracoid/pectoralis minor space. Arterial thoracic outlet is the least common and accounts for roughly 1% of all cases.


TOS can arise from various causes, including anatomic variations, blunt force trauma, muscle hypertrophy, and iatrogenic sources. Nearly 50% of patients with arterial TOS have cervical ribs and one third have soft tissue anomalies. Individuals who perform repetitive overhead arm movements are at increased risk of developing arterial TOS.


Diagnosing TOS can be challenging due to the lack of established criteria. Symptomatic patients may present with absent or diminished pulses, abnormal skin color changes, or a palpable supraclavicular pulse. In severe cases, patients may present with critical limb ischemia or posterior circulation stroke. However, others may be asymptomatic with the only sign being a pulsatile mass in the supraclavicular space.


If TOS is suspected, initial evaluation should include x-rays to assess for any anatomical causes, followed by advanced imaging such as CTA or MRA. Many patients with vascular thoracic outlet have greater functional impairment compared to those with nonvascular symptoms.


Treatment for for arterial thoracic outlet syndrome is not standarized and dependens on the underlying etiology. Most symptomatic patients with arterial thoracic outlet will undergo surgical decompression, which includes rib resection and complete scalenectomy. Recovery from surgery generally takes about 8-12 weeks.

Editor's Comments:
This case of a collegiate track athlete presenting with a pulsatile neck mass offers a unique and multifaceted educational opportunity for sports medicine physicians. The presentation of a pulsatile mass in the supraclavicular area, combined with the patients athletic background and subsequent imaging findings, underscores several critical areas of learning that are essential for both clinical practice and academic advancement.

The case highlights the importance of constructing a comprehensive differential diagnosis when encountering uncommon presentations like a pulsatile neck mass. The use of multiple imaging modalities, including ultrasound, CTA, and specific protocols for thoracic outlet syndrome, exemplifies the integration of diagnostic imaging in clinical decision making. Each imaging study contributed unique information that was critical to accurately diagnosing the patients condition, a mild aneurysmal change of the left subclavian artery with associated bilateral cervical ribs. This case illustrates the pivotal role of imaging in confirming clinical suspicions and guiding treatment plans, which is particularly relevant in sports medicine where imaging often influences return to play decisions.

This case also serves as a valuable educational tool in understanding the complexities of thoracic outlet syndrome, especially the rare arterial form. The detailed exploration of TOS in this patient, including the anatomical variations such as cervical ribs, provides insight into the pathophysiology of the syndrome. It also emphasizes the need for clinicians to be aware of the various forms of TOS, their presentations, and the appropriate diagnostic workup and management strategies, which is crucial for preventing long-term complications in athletes.

The discussion of the role of surgical intervention in arterial thoracic outlet syndrome, offers critical insights into the decision making process for treating complex vascular conditions in athletes. The case underscores the importance of individualized patient care, weighing the risks and benefits of surgical decompression, and understanding the post operative recovery timeline, which is essential for clinicians involved in the care of athletes with similar conditions.

References:
de Kleijn RJCMF, Schropp L, Westerink J, van Hattum ES, Petri BJ, de Borst GJ. Functional outcome of arterial thoracic outlet syndrome treatment. Front Surg. 2023 Jan 16;9:1072536. doi: 10.3389/fsurg.2022.1072536. PMID: 36726955; PMCID: PMC9885003.

Farzam, F., Barakzai, Y., and Foladi, N. Arterial Thoracic Outlet Syndrome by a Commonly Overlooked Anomaly, the Cervical Rib: A Case Report. Radiology Case Reports. 2023 18 (9): 3351-3356. doi.org/10.1016/j.radcr.2023.06.068.

Garraud T, Pomares G, Daley P, Menu P, Dauty M, Fouasson-Chailloux A. Thoracic Outlet Syndrome in Sport: A Systematic Review. Front Physiol. 2022 Jun 8;13:838014. doi: 10.3389/fphys.2022.838014. PMID: 35755427; PMCID: PMC9214221.

Huang J, Lauer J, Zurkiya O. Arterial thoracic outlet syndrome. Cardiovasc Diagn Ther. 2021 Oct;11(5):1118-1124. doi: 10.21037/cdt-20-149. PMID: 34815963; PMCID: PMC8569270.

Teijink SBJ, Goeteyn J, Pesser N, van Nuenen BFL, Thompson RW, Teijink JAW. Surgical approaches for thoracic outlet decompression in the treatment of thoracic outlet syndrome. J Thorac Dis. 2023 Dec 30;15(12):7088-7099. doi: 10.21037/jtd-23-546. Epub 2023 Dec 14. PMID: 38249887; PMCID: PMC10797336.

Return To The Case Studies List.