患者为45岁女性，左上肢疼痛伴发凉、麻木及乏力约2年，影像显示颈肋压迫左锁骨下动脉，形成明显狭窄及狭窄后扩张。经多学科讨论后，团队采用锁骨上入路，切除颈肋并解除压迫，随后切除病变血管段并完成血管重建。术后5个月随访显示，患者症状明显改善，未见上肢无力。
背景
Arterial thoracic outlet syndrome (ATOS) is the rarest subtype of thoracic outlet syndrome, but it may cause serious vascular complications. Congenital bony abnormalities, particularly cervical ribs, are strongly associated with ATOS. Chronic subclavian artery compression can lead to stenosis, post-stenotic dilatation or aneurysm formation, thrombosis, distal embolization, and limb ischemia.
病例摘要
A 45-year-old female nurse presented with a two-year history of left upper-extremity pain radiating from the shoulder to the hand, numbness, painful paresthesia, coldness and pallor—particularly in the second and third fingers—and worsening symptoms during overhead activity. Cervical MRI and ENMG did not demonstrate a neurological cause. Plain radiography revealed bilateral cervical ribs.
诊断检查
CT angiography demonstrated compression of the left subclavian artery between the cervical rib and scalene muscle, with significant stenosis, marked post-stenotic dilatation/aneurysmal degeneration, and distal arterial occlusion. DSA confirmed the vascular abnormality. The diagnosis was symptomatic cervical rib-associated ATOS complicated by aneurysmal arterial degeneration and distal occlusion.
手术治疗
Following multidisciplinary evaluation, surgical treatment was performed through a supraclavicular approach. The phrenic nerve and the superior, middle, and inferior trunks of the brachial plexus were identified and preserved. Anterior and middle scalenectomy and complete cervical rib resection provided thoracic outlet decompression. The first rib was preserved because preoperative imaging and intraoperative exploration demonstrated that the compression was attributable to the cervical rib without significant first-rib involvement.
After decompression, the aneurysmal subclavian artery was fully exposed. Proximal and distal vascular control was obtained, the diseased aneurysmal segment was dissected and resected, and arterial continuity was restored using a 6-mm ringed PTFE graft with 6-0 Prolene sutures. Intraoperative Doppler ultrasonography confirmed graft patency and adequate distal blood flow.
术后情况
Postoperative radiography confirmed complete left cervical rib resection. The patient received antiplatelet therapy and underwent periodic Doppler ultrasonographic surveillance. At five months, her preoperative symptoms had significantly improved, with no clinical evidence of upper-extremity ischemia.
总结
ATOS is rare but potentially limb-threatening. Early recognition is essential before chronic compression progresses to irreversible arterial damage. Treatment should address both the anatomical cause of compression and the resulting arterial complication. In selected patients, the supraclavicular approach allows thoracic outlet decompression and vascular reconstruction through the same surgical field.
Key message: Early recognition → adequate decompression → treatment of arterial damage → prevention of limb-threatening complications.
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