History and Physical Examination

A patient with an acute occlusion presents with a cold, painful, pulseless upper extremity. Axillary, brachial, and radial pulses are generally absent. When the occlusion is secondary to atherosclerotic changes, various prodromes and manifestations may be observed.

The patient may present with no symptoms or may have upper-extremity claudication secondary to exertion. If the condition has precipitated a steal syndrome, no symptoms are typically present.

The examining physician should be aware of the rare presentation of various neurologic symptoms and findings that may be associated with the steal syndromes, including syncope, vertigo, ataxia, sensory loss, visual changes, and stroke, depending on the vessels involved in the steal.

The affected upper extremity may or may not demonstrate diminished pulses. Blood pressure differences between affected and unaffected sides may be noted.

Complications

Potential complications of subclavian artery thrombosis secondary to atherosclerotic disease include distal embolization to the digits and neurologic symptoms, including stroke secondary to a steal syndrome. If the subclavian artery thrombosis is secondary to thoracic outlet problems, subclavian vein thrombosis can occur as well.^[8] Accompanying neurologic symptoms resulting from brachial plexus compression can also be associated with the syndrome.

Workup

Mubarik A, Iqbal AM. Subclavian Artery Thrombosis. Treasure Island, FL: StatPearls; 2023. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Zimmerman NB. Occlusive vascular disorders of the upper extremity. Hand Clin. 1993 Feb. 9 (1):139-50. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Karpenko A, Starodubtsev V, Ignatenko P, Gostev A. Endovascular Treatment of the Subclavian Artery Steno-Occlusive Disease. J Stroke Cerebrovasc Dis. 2017 Jan. 26 (1):87-93. [QxMD MEDLINE Link].
Hood DB, Kuehne J, Yellin AE, Weaver FA. Vascular complications of thoracic outlet syndrome. Am Surg. 1997 Oct. 63 (10):913-7. [QxMD MEDLINE Link].
Jones CS, Verde F, Johnson PT, Fishman EK. Nontraumatic Subclavian Artery Abnormalities: Spectrum of MDCT Findings. AJR Am J Roentgenol. 2016 Aug. 207 (2):434-41. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Usai MV, Bosiers MJ, Bisdas T, Torsello G, Beropoulis E, Kasprzak B, et al. Surgical versus endovascular revascularization of subclavian artery arteriosclerotic disease. J Cardiovasc Surg (Torino). 2020 Feb. 61 (1):53-59. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Cheun TJ, Jayakumar L, Sideman MJ, Pounds LL, Davies MG. Upper extremity arterial endovascular interventions for symptomatic vascular access-induced steal syndrome. J Vasc Surg. 2019 Dec. 70 (6):1896-1903.e1. [QxMD MEDLINE Link].
Galyfos GC, Kakisis I, Maltezos C, Geroulakos G. Open versus endovascular treatment of subclavian artery atherosclerotic disease. J Vasc Surg. 2019 Jan. 69 (1):269-279.e7. [QxMD MEDLINE Link].
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 Nov-Dec. 12 (6):403-6. [QxMD MEDLINE Link].
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. 2012 Jan. 35 (1):121-5; discussion 125-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Fugate MW, Rotellini-Coltvet L, Freischlag JA. Current management of thoracic outlet syndrome. Curr Treat Options Cardiovasc Med. 2009 Apr. 11 (2):176-83. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Santra G, Banerjee S, De D, Bhattacharya K. Right subclavian artery thrombosis due to cervical rib. J Assoc Physicians India. 2012 Sep. 60:51. [QxMD MEDLINE Link].
Thompson RW. Challenges in the treatment of thoracic outlet syndrome. Tex Heart Inst J. 2012. 39 (6):842-3. [QxMD MEDLINE Link]. [Full Text].
Thompson JF, Webster JH. First rib resection for vascular complications of thoracic outlet syndrome. Br J Surg. 1990 May. 77 (5):555-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mrad IB, Miri R, Mazzaccaro D, Mrad MB, Mleyhi S, Zairi I, et al. Endovascular therapy for steno-occlusive subclavian artery disease early and long-term outcomes in a multicentric Tunisian study. Ann Ital Chir. 2022. 93:470-475. [QxMD MEDLINE Link].
Burihan E, Soma F, Iared W. Angioplasty versus stenting for subclavian artery stenosis. Cochrane Database Syst Rev. 2011 Oct 5. CD008461. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Owens CA. Ultrasound-Enhanced Thrombolysis: EKOS EndoWave Infusion Catheter System. Semin Intervent Radiol. 2008 Mar. 25 (1):37-41. [QxMD MEDLINE Link].

Media Gallery

The anatomy of the subclavian artery in the thoracic outlet.
Carotid-subclavian bypass for subclavian steal syndrome.
Subclavian-subclavian or axillary-axillary bypass for subclavian artery occlusion.

of 3

Author

Mary C Mancini, MD, PhD, MMM

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel S Schwartz, MD, MBA, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic Health Services

Daniel S Schwartz, MD, MBA, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey Lawrence Kaufman, MD Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine

Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Subclavian Artery Thrombosis Clinical Presentation

History and Physical Examination

Complications

References

Tables

Contributor Information and Disclosures

What would you like to print?