A case of concomitant subclavian steal syndrome and thoracic outlet syndrome

Abstract

A 59-year-old woman presented with dizziness and numbness of her left upper limb. Computed tomography (CT) angiography revealed an occlusion of the subclavian artery at its origin, leading to a diagnosis of subclavian steal syndrome. She was treated with percutaneous angioplasty and stenting; however, her symptoms did not improve. CT angiography of the arm in the elevated position revealed subclavian artery stenosis at the costoclavicular space, and the diagnosis was neurogenic thoracic outlet syndrome (TOS). First-rib resection was performed, and the symptoms disappeared immediately after surgery. TOS should be considered when symptoms persist despite subclavian steal syndrome treatment. Physical examination and CT imaging with the arm elevated aid in diagnosing TOS.

Keywords: Endoscopic-assisted infraclavicular approach; Subclavian steal; Subclavian steal syndrome; Thoracic outlet; Thoracic outlet syndrome.

Fig 1

Computed tomography (CT) angiography with the arm dropped. Before (A) and after (B) the endovascular dilation with a stent.

Fig 2

Computed tomography (CT) angiography with the arm elevated showing stenosis of the subclavian artery at the costoclavicular space.

Fig 3

Operative findings. A, A transverse infraclavicular incision reveals the clavicle, pectoralis major, and supraclavicular nerve. B, The subclavian vein and first rib are revealed after the excision of the subclavian muscle. C, Endoscopic view of the first rib and anterior scalene muscle. D, Endoscopic view of the first rib and middle scalene muscle. E, Resection of the first rib.

Fig 4

Postoperative radiographs of the first rib.

Fig 5

Postoperative computed tomography (CT) angiography with the arm elevated, showing an improvement of the subclavian artery stenosis at the costoclavicular space.