Case Presentation: A 52-year-old female with a past medical history of hypertension and type-2 diabetes mellitus presented with acute onset pain and numbness in her left arm-elbow region radiating to her left hand while working in her garden. She had a history of deep vein thrombosis in her left upper extremity (LUE) about five years before presentation, for which she was started on anticoagulation with apixaban which the patient opted not to continue. Vitals on presentation was stable. The LUE physical exam was significant for cold, non-palpable, or dopplerable radial, ulnar, or brachial pulse and decreased sensation to all digits. Motor exam of LUE had intact grip, finger ab/adduction, wrist extension/flexion. Labs, including complete blood count, basic metabolic panel, PT, PTT, and INR were unremarkable. Computerized tomographic angiography (CTA) imaging of LUE was positive for acute brachial artery obstruction, thrombosed subclavian artery aneurysm, and bilateral cervical rib. The thrombosed subclavian artery aneurysm was considered to be secondary to a cervical rib. She was anticoagulated with heparin and underwent a thrombectomy of her left axillary, brachial, radial, and ulnar arteries. One week later, she underwent a left common carotid to left axillary artery bypass with a prosthetic. Her left cervical rib was not removed at the time due to dense adhesions. Post-operatively, the patient was stable and asymptomatic with complete pain relief and palpable radial pulse. She was discharged with Eliquis and instructions to follow up with vascular surgery. She is scheduled for an elective cervical rib resection, starting with the right side.

Discussion: The diagnosis and management of arterial thoracic outlet syndrome remain challenging. A complete color Doppler examination of the upper extremity arteries in every young patient presenting with thromboembolic blockage of the upper-limb arteries must be performed together with the scalene maneuver (hyperabduction maneuver). As a result of chronic compression and injury to the subclavian artery brought on by bone anomalies, most frequently a cervical rib, aneurysm formation is the result of arterial thoracic outlet syndrome.

Conclusions: Neurovascular compressive symptoms affecting the upper extremities are becoming more recognized and understood and should be immediately reported to specialists and surgical facilities upon diagnosis.