Thoracic Outlet Syndrome with Subclavian Artery Thrombosis Undetectable by Magnetic Resonance Angiography

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Acute vascular insufficiency in the upper limb suggests the possibility of an embolic phenomenon1-3. The most common source of upper-extremity emboli is from the subclavian artery, with less likely potential sources being the superficial palmar arch and cardiac vessels1. Thoracic outlet compression represents the most frequently reported cause of subclavian arterial disease1,2,4, and arterial-related problems associated with thoracic outlet compression, although extremely uncommon, have also been reported5. In addition to the detection of historical features and the performance of provocative maneuvers during the clinical examination, the use of noninvasive magnetic resonance angiography has been reported to be particularly helpful in the diagnosis of thoracic outlet compression6,7. We report an unusual clinical case in which a peripheral embolic disorder was identified in a young adult with an associated history of recurrent shoulder instability as well as a deformity of the first rib. Although magnetic resonance angiography failed to identify the pathology in the subclavian artery, it was subsequently confirmed by arteriography. The patient was informed that data concerning this case would be submitted for publication. Ahealthy nineteen-year-old college freshman had pain in the right wrist after being struck by a football during a friendly competition. The symptoms persisted for several weeks. When the patient returned home from college, he was evaluated by a hand specialist who suspected the diagnosis of extensor carpi ulnaris tendinitis and treated the condition with a corticosteroid injection. The wrist pain continued and became associated with diffuse numbness, alteration in temperature, and pain extending up the forearm. Of note is the fact that, following a traumatic ipsilateral shoulder dislocation at twelve years of age, the patient had experienced three to four episodes of shoulder subluxation during strenuous activities, although …