Post-traumatic axillary artery thrombosis dissolution with low-dose intra-arterial streptokinase

Abstract

This case demonstrates an unusual complication of clavicular fracture. We feel that at the time of injury a large force depressed the distal clavicle causing momentary compression to the axillary artery resulting in injury to, or around the wall of the artery. This led to secondary thrombosis within the lumen. Intra-arterial thrombolytic therapy was used to avoid arterial surgery in this difficult situation. Case report A healthy 35-year-old man sustained a distally displaced fracture of the right clavicle when struck by a swinging crane on a North Sea oil platform. This was treated by standard non-operative management. Two weeks later he became aware of cold Angers, numbness, pain and weakness in his right forearm and hand and presented to a trauma clinic, where symptoms were attributed to a brachial plexus neurapraxia and treated expectantly. Increased weakness was noted (Grade 415 MRC grading in each muscle group) z weeks later and the right bra&al, radial and ulnar pulses were absent. In addition, he had impaired sensation on the lateral aspect of his arm. After admission to a medical ward, arteriography revealed a 5-cm occlusion of the axillary artery with poor collateral circulation. A 5G arterial catheter was advanced into the thrombus via the right femoral approach under fluoroscopic control (Figure ~a). Streptokinase was infused via the catheter at 5000units/h, but concomitant herapin was not used. The prothrombin time (PT), kaolin-cephalin clotting time (KCCT) and platelets all remained normal. The fibrin degradation products (FDPs) and fibrinogen titres were monitored 4 hourly. The patient was checked regularly for clinical evidence of bleeding and arteriography was used to assess clot lysis. Observed changes in fibrinogen titres and FDPs did not necessitate an alteration in infusion rate. At 36 h after starting the infusion there was increasing pain in the arm secondary to reperfusion. At 48 h arteriography demonstrated some clot lysis. The catheter was advanced further into the clot. At 98 h the pain had resolved and the artery had become patent, but with some residual thrombus. The infusion was maintained until 108 h when the fibrinogen titres and FDP levels were no longer acceptable. Arteriography at this time revealed no thrombus, but showed a residual stenosis which was subsequently treated by translurninal angioplasty (Figure lb). Full power and sensation returned to the arm, with easily palpable radial and ulnar pulses.