Hybrid Therapy for Acute Upper Limb Ischemia with Thoracic Outlet Syndrome: A Case Report

Abstract Background Arterial thoracic outlet syndrome (ATOS) is characterised by upper extremity ischemia or aneurysm-like disease caused by external compression of the subclavian or axillary arteries at the thoracic outlet. ATOS is the least common type of thoracic outlet syndrome (TOS), accounting for 1%–2% of all TOS cases. Acute limb ischemia (ALI) is a life-threatening condition requiring urgent assessment and management. Although ALI most commonly affects the lower limb, 20% of cases involve the upper limb. The first-line treatment for ALI is surgical thrombectomy; however, some reports have found endovascular treatment to be effective. Case Presentation A 45-year-old man complained of rest pain and paraesthesia in the left arm for the past week. Physical examination revealed coldness and pallor of the left upper limb, and absence of the brachial pulse. Computed tomography revealed pseudarthrosis due to left cervical ribs, aneurysmal change of the left subclavian artery with thrombus, and distal occlusion beyond the brachial artery. Electrocardiography showed a normal sinus rhythm and echocardiography showed no thrombus in the left ventricle. We diagnosed acute upper limb ischemia due to subclavian artery aneurysms with TOS. He underwent emergent surgical thrombectomy via the left brachial artery. Surgical resection of the cervical and first rib was performed 1 month later, and endovascular treatment with a stent-graft was performed for the aneurysmal change 3 months later. Discussion We report a rare case of TOS with aneurysmal change and thrombosis. ATOS should be considered in acute upper limb ischemia when the embolic cause is unknown.