Subclavian Artery Thrombosis Treatment & Management
- Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
Therapeutic intervention is indicated in any symptomatic patient once the etiology of the symptoms has been defined. For instances of upper-extremity claudication or acute thrombosis in which the problem has been attributed to the subclavian artery, intervention should be planned and executed. For patients in whom cerebrovascular symptoms predominate, a careful neurologic evaluation must be undertaken in order to isolate the problem. Once the anatomic aberration has been defined, intervention is indicated if the subclavian artery is involved.
Contraindications to surgical intervention include the following:
Inadequate distal runoff
Inadequate vessel size
Marked collateralization of the occluded area
Concomitant medical problems that would endanger the patient during a surgical intervention
Future therapy for subclavian artery thrombosis will most likely involve the use of endovascular stents.[7, 8] As technology improves and a better understanding of restenosis issues is achieved, stenting of these lesions will be more commonplace.[9, 10] The advent of stenting potentially allows successful treatment of patients with greater medical challenges; however, the presence of appropriate arterial runoff and adequate artery size are imperative in order to ensure the success of the procedure.
In any operative procedure for subclavian artery thrombosis, care must be taken to protect the thoracic duct from damage.
Early diagnosis and therapy of subclavian artery thrombosis are indicated to prevent disabling upper-extremity ischemia and gangrene. As a temporizing measure, the use of catheter-directed thrombolytic therapy may be indicated for superimposed clot formation in an area of stenosis until definitive treatment of the obstruction can be undertaken.
Prolonged anticoagulation therapy for an obvious mechanical problem is not indicated. Anticoagulation may be considered as supplemental therapy after surgical intervention.
Surgery to correct subclavian artery thrombosis is the treatment of choice. Interventions include catheter-based procedures and formal operative procedures.
Angioplasty and stenting of stenotic and even occluded arteries have been undertaken successfully with adequate patency rates and minimal morbidity. These interventions are particularly appropriate for atherosclerotic arteries. A study to determine if stenting alone is superior proved inconclusive. A study from Germany found that endovascular therapy was safe and effective for treating stenosis and occlusion of the subclavian artery and yielded excellent long-term patency. A large-scale multicenter study from Japan found that primary endovascular therapy for subclavian artery disease yielded good outcomes with regard to perioperative complication and long-term patency rates.
Subclavian artery occlusion secondary to thoracic outlet syndrome or muscular compression is treated by excision of the anatomic structure compressing the artery, whether muscle or bone. The artery may or may not require additional reconstruction, depending on the presence or absence of intimal damage.
The occluded artery may require a bypass procedure, depending on the location of the occlusion or the presence of a subclavian steal syndrome. The bypass options include subclavian-carotid, subclavian-subclavian, and axillary-axillary bypasses. Another possible bypass option is transposition of the subclavian artery to the ipsilateral carotid artery.
Careful assessment of patients with thoracic outlet syndrome will be required because of the complexity of this problem, the multiple structures involved, and the high-profile medicolegal issues that arise with treatment of these patients. Operative treatment of the arterial complications of the thoracic outlet syndrome should be performed. However, careful evaluation of the potentially associated venous and neurologic pathologies should be undertaken prior to any operative therapy.
After the appropriate diagnostic studies have been performed to define the problem, operative preparation should be carried out. Administer preoperative prophylactic antibiotic therapy in the form of a first-generation cephalosporin. Perform appropriate preoperative medical screening to assess for evidence of other atherosclerotic disease, such as coronary, carotid, or peripheral vascular occlusions.
For patients in whom the occlusion is secondary to atherosclerotic disease, perform a bypass of the area. For subclavian steal syndrome, a carotid-subclavian bypass using a ribbed synthetic tube graft is the procedure of choice (see the image below).
Depending upon the location of the occlusion, subclavian-subclavian or axillary-axillary bypass can be undertaken using a ribbed synthetic conduit (see the image below).
Because of the position of the graft and the necessity of crossing bony structures in some cases, autologous vein conduits have limited patency.
For patients in whom thoracic outlet compression is the cause of the thrombosis, cervical rib resection via a supraclavicular incision appears to be adequate treatment. Resection of the midportion of the clavicle is sometimes needed for exposure. Undertake arterial resection because the intima of the vessel is damaged. Graft interposition may or may not be required. Redundancy of the normal adjacent artery may allow end-to-end reconstruction. If a graft is required for arterial reconstruction, a large autogenous saphenous vein or expanded polytetrafluoroethylene or Dacron fabric grafts may be used. First-rib resection may be indicated in these instances as well, depending on the size of the thoracic outlet.
Check distal upper-extremity pulses immediately after the operative procedure, while the field is still sterile. Maintain careful observation for the development of muscular compartment syndromes, and perform compartment measurements if indicated. Concomitant fasciotomies may be indicated, depending on the length of ischemia suffered by the extremity prior to revascularization.
Postoperative pleural effusions should be promptly evaluated for the presence of chyle, which would be indicative of thoracic duct injury. Prompt therapeutic measures should be undertaken if this complication occurs.
Complications of the operative procedure can include injury to the thoracic duct. Complications from operative interventions to address the arterial occlusion can include graft occlusion (acute and chronic), stent migration, stent occlusion, bleeding, and infection. Although rare, the possibility of postoperative bleeding should be reviewed with the patient before the operative intervention. Promptly address bleeding complications by reoperation in order to correct the problem.
Perform postprocedural angiography at prescribed times after the operative intervention in order to assess the patency of the graft or stent. One suggested timing sequence for the studies is at 1 month and 6 months, provided that the patient remains asymptomatic. In the interim, noninvasive Doppler imaging can be used to assess distal flow to the extremity.
Nuber GW, McCarthy WJ, Yao JS, Schafer MF, Suker JR. Arterial abnormalities of the shoulder in athletes. Am J Sports Med. 1990 Sep-Oct. 18(5):514-9. [Medline].
Mandalam KR, Rao VR, Gupta AK, Joseph S, Unni NM, Rao AS. Occlusion of an aberrant right subclavian artery arising from a Kommerel diverticulum. J Vasc Interv Radiol. 1993 Jul-Aug. 4(4):577-9. [Medline].
Zimmerman NB. Occlusive vascular disorders of the upper extremity. Hand Clin. 1993 Feb. 9(1):139-50. [Medline].
Nehler MR, Taylor LM Jr, Moneta GL, Porter JM. Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg. 1997 May. 132(5):527-32. [Medline].
Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. 1997 Oct. 63(10):913-7. [Medline].
Laitt RD, Thompson JF, Goddard P, Wakeley CJ, Murphy P, Lamont P. Subclavian artery aneurysm: the role of magnetic resonance imaging. Cardiovasc Surg. 1994 Oct. 2(5):612-4. [Medline].
Cohen JE, Rajz G, Gomori JM, Verstandig A, Berlatzky Y, Anner H, et al. Urgent endovascular stent-graft placement for traumatic penetrating subclavian artery injuries. J Neurol Sci. 2008 Sep 15. 272(1-2):151-7. [Medline].
Shalhub S, Starnes BW, Hatsukami TS, Karmy-Jones R, Tran NT. Repair of blunt thoracic outlet arterial injuries: an evolution from open to endovascular approach. J Trauma. 2011 Nov. 71(5):E114-21. [Medline].
Varcoe R, Smith W. Use of a cutting balloon and a paclitaxel-coated balloon to treat recurrent subclavian in-stent restenosis causing coronary subclavian steal syndrome. Cardiovasc Revasc Med. 2011 Jul 26. [Medline].
Miyakoshi A, Hatano T, Tsukahara T, Murakami M, Arai D, Yamaguchi S. Percutaneous transluminal angioplasty for atherosclerotic stenosis of the subclavian or innominate artery: angiographic and clinical outcomes in 36 patients. Neurosurg Rev. 2011 Jun 4. [Medline].
Rogers JH, Calhoun RF 2nd. Diagnosis and management of subclavian artery stenosis prior to coronary artery bypass grafting in the current era. J Card Surg. 2007 Jan-Feb. 22(1):20-5. [Medline].
Dave B, Bhatt N, Gupta M, Khalasi Y, Balasubramanya KS. Subclavian artery thrombosis--management with thrombolysis and angioplasty. J Indian Med Assoc. 2004 Sep. 102(9):519-20, 527. [Medline].
Burihan E, Soma F, Iared W. Angioplasty versus stenting for subclavian artery stenosis. Cochrane Database Syst Rev. 2011 Oct 5. CD008461. [Medline].
Bradaric C, Kuhs K, Groha P, Dommasch M, Langwieser N, Haller B, et al. Endovascular therapy for steno-occlusive subclavian and innominate artery disease. Circ J. 2015. 79 (3):537-43. [Medline].
Soga Y, Tomoi Y, Fujihara M, Okazaki S, Yamauchi Y, Shintani Y, et al. Perioperative and Long-term Outcomes of Endovascular Treatment for Subclavian Artery Disease From a Large Multicenter Registry. J Endovasc Ther. 2015 Aug. 22 (4):626-33. [Medline].
Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. 2009 Apr. 11(2):176-83. [Medline].
Thompson JF, Webster JH. First rib resection for vascular complications of thoracic outlet syndrome. Br J Surg. 1990 May. 77(5):555-7. [Medline].
Baraki H, Hagl C, Khaladj N, Kallenbach K, Weidemann J, Haverich A. The frozen elephant trunk technique for treatment of thoracic aortic aneurysms. Ann Thorac Surg. 2007 Feb. 83(2):S819-23; discussion S824-31. [Medline].
Boas N, Desmoucelle F, Bernadet V, Franceschi JC. Rare cause of acute ischemia of the right upper extremity: thrombosis of a retroesophageal subclavian artery. Ann Vasc Surg. 2002 May. 16(3):387-90. [Medline].
Chang KZ, Likes K, Davis K, Demos J, Freischlag JA. The significance of cervical ribs in thoracic outlet syndrome. J Vasc Surg. 2013 Mar. 57(3):771-5. [Medline].
Dagenais F, Dumont E, Voisine P. Intramural hematoma of the arch and ascending aorta owing to acute aortic syndrome of the descending aorta: to stent or not to stent?. J Endovasc Ther. 2008 Oct. 15(5):544-9. [Medline].
Edwards WH. An unsuspected cause for recurrent angina: subclavian artery stenosis. Am Surg. 1995 Dec. 61(12):1057-60. [Medline].
Fan Z, Roedersheimer R, Lohr J. Systemic thrombolysis using tissue plasminogen activator for a patient with paradoxic embolism: a case report. Vasc Endovascular Surg. 2007 Apr-May. 41(2):136-9. [Medline].
Golcman L, Berginer VM, Szendro G, Hoda J, Louson Z. Prominent somnolence and cerebellar syndrome in subclavian artery thrombosis--a case report. Angiology. 1987 Dec. 38(12):912-5. [Medline].
Hay E, Cohen H, Pasik S. Acute thrombosis of subclavian artery during CPR. Ann Emerg Med. 1987 Apr. 16(4):447-51. [Medline].
Hendler MF, Meschengieser SS, Blanco AN, Alberto MF, Salviú MJ, Gennari L. Primary upper-extremity deep vein thrombosis: high prevalence of thrombophilic defects. Am J Hematol. 2004 Aug. 76(4):330-7. [Medline].
Henry M, Amor M, Henry I. Percutaneous transluminal angioplasty of the subclavian arteries. J Endovasc Surg. 1999 Feb. 6(1):33-41. [Medline].
Mendelsohn AM, Buzzard CJ, Lerner NB, Ling FS. Transumbilical balloon angioplasty of subclavian artery thrombosis in a neonate. Catheter Cardiovasc Interv. 2000 Jan. 49(1):56-60. [Medline].
Muzaffar M, Fatimi SH, Tariq M, Hanif HM. Subclavian steal syndrome secondary to subclavian artery thrombosis in a patient with homocysteinemia and its successful treatment. J Pak Med Assoc. 2012 Oct. 62(10):1118-20. [Medline].
Rapp JH, Reilly LM, Goldstone J, Krupski WC, Ehrenfeld WK, Stoney RJ. Ischemia of the upper extremity: significance of proximal arterial disease. Am J Surg. 1986 Jul. 152(1):122-6. [Medline].
Riesenman PJ, Farber MA, Mendes RR, Marston WA, Fulton JJ, Keagy BA. Coverage of the left subclavian artery during thoracic endovascular aortic repair. J Vasc Surg. 2007 Jan. 45(1):90-4; discussion 94-5. [Medline].
Santra G, Banerjee S, De D, Bhattacharya K. Right subclavian artery thrombosis due to cervical rib. J Assoc Physicians India. 2012 Sep. 60:51. [Medline].
Tyagi S, Rangasetty UC, Kaul UA. Stenting of a large thrombus-containing subclavian artery stenosis using a distal protection device. Indian Heart J. 2003 May-Jun. 55(3):262-4. [Medline].
Vanherweghem JL, Cabolet P, Dhaene M, Goldman M, Stolear JC, Sabot JP. Complications related to subclavian catheters for hemodialysis. Report and review. Am J Nephrol. 1986. 6(5):339-45. [Medline].
Vinsonneau U, Castellant P, Traore A, Cornily JC, Pennec PY, Etienne Y, et al. [Floating thrombus in an aberrant right subclavian artery: a rare cause of peripheral arterial embolic events]. Rev Med Interne. 2008 Nov. 29(11):908-11. [Medline].
Witz M, Lehman J, Shnaker A, Korzets Z. Acute subclavian and brachial artery thrombosis as a complication of the nephrotic syndrome. Isr Med Assoc J. 2004 Jul. 6(7):441-2. [Medline].
Witz M, Lehmann J, Korzets Z. Acute brachial artery thrombosis as the initial manifestation of human immunodeficiency virus infection. Am J Hematol. 2000 Jun. 64(2):137-9. [Medline].
Zeller T, Frank U, Bürgelin K, Sinn L, Horn B, Roskamm H. Acute thrombotic subclavian artery occlusion treated with a new rotational thrombectomy device. J Endovasc Ther. 2002 Dec. 9(6):917-21. [Medline].