Management of a patient with arterial thoracic outlet syndrome and Srb anomaly

Abstract

Thoracic outlet syndrome (TOS) is a group of disorders characterized by the compression of neurovascular structures at the thoracic outlet. Arterial TOS, the least common but most severe form, carries significant thromboembolic risks and has a known association with cervical ribs. Synostosis of a complete first and second rib, termed the Srb anomaly, is rare and occurs in approximately 0.2% of the population. Here, we present a unique case of a 17-year-old boy with right upper extremity claudication owing to arterial TOS from an Srb anomaly. This case emphasizes the successful management of an uncommon condition, the importance of accurate diagnosis and timely intervention.

Keywords: Anomalous rib; Rib resection; Thoracic outlet.

Fig 1

Preoperative computed tomography (CTA) chest and right upper extremity show a right subclavian artery compression between the first rib and the clavicle and a synostosis of the right first and second rib consistent with Srb anomaly.

Fig 2

(A) Right upper extremity angiogram show an occlusion of the brachial artery just above the elbow with distal reconstitution. (B) Intravascular ultrasound (IVUS) show complete collapse of the artery with provocative maneuvers. (C) Right upper extremity angiogram with provocative maneuvers.

Fig 3

(A) Intraoperative image taken with laparoscope showing the patients anatomy. (B) An image of removed first rib.