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Journal of Experimental Medical & Surgical Research
Cercetãri Experimentale & Medico-Chirurgicale
Year XVIII · Nr.4/2011 · Pag. 206 - 209
JOURNAL of
Experimental
Medical
Surgical
R E S E A R C H
COLLATERAL PATHWAYS IN PATIENT WITH DISTAL
RIGHT SUBCLAVIAN ARTERY OCCLUSION. AN MDCT
ANGIOGRAPHIC PICTORIAL ESSAY
H. Pleº1,2,
G.D. Miclãuº2,
I. Avram3,
Gh. Nodiþi4, 5
Received for publication:
15.06.2011
Revised: 19.09.2011
Summary:
In this study, the authors describe a rare case of a 78-year-old female with the presence of a
distal occlusion of the right subclavian artery, located in relation with the superior face of
the first right rib, with a length of 25.5 mm. The proximal end of the subclavian occlusion has
an endoluminal diameter of 5.9 mm, and the distal end has an endoluminal diameter of 5.1
mm. The thyrocervical trunk arises form the superior wall of the subclavian artery at 3.7 mm
proximal to the proximal end of the subclavian occlusion. The subscapular artery arises
from the first part of the axillary artery, at 67.4 mm distal to the distal end of the subclavian
occlusion. After 51 mm from the origin, the subscapular artery is forking in thoracodorsal
artery and circumflex scapular artery. At the level of infraspinous fossa the subscapular
artery branch profusely and connects with branches of the suprascapular and dorsal
scapular arteries. These anastomoses partcipate to achieve the collateral pathways of
proximal portion of subclavian artery and axillar artery.
Keywords:
subclavian artery, occlusion, interscalene triangle, collateral patways.
Rezumat:
În acest studiu, autorii descriu un caz rar la un bãrbat de 69 de ani, cu prezenþa unei ocluzii
distale a arterei subclavii drepte, localizatã în raport cu faþa superioarã a primei coaste, cu o
lungime de 25.5 mm. Capãtul proximal al ocluziei subclavii are un diametru endoluminal de
5.9 mm, ºi unul distal de 5.1 mm. Trunchiul tirocervical ia naºtere de pe peretele superior al
arterei subclavii, la 3.7 mm de capãtul proximal al ocluziei subclavii. Artera subscapularã
are originea din prima porþiune a arterei axilare, la 67.4 mm distal de capãtul distal al ocluziei
subclavii. La 51 mm de origine, artera subscapularã se împarte în artera toracodorsala ºi
artera corcumflexã scapularã. La nivelul fosei infraspinoase artera subscapularã se ramificã
abundent ºi se conecteazã cu ramurile arterei subscapularã ºi arterei dorsale a scapulei.
Aceste anastomoze participã la realizarea unei circulaþii colaterale între proþiunea proximalã
a arterei subclavii ºi artera axilarã.
Cuvinte cheie:
artera subclavie, ocluzie, triunghiul interscalenic, cãi colaterale.
1. - Department of Neurosciences, Clinic of Neurosurgery, ''Victor Babes'' University of Medicine and Pharmacy, Timisoara,
Romania
2. - Neuromed Diagnostic Imaging Centre, Timisoara, Romania
3. - First Clinic of Surgery, Department of Surgery II, ''Victor Babes'' University of Medicine and Pharmacy, Timisoara,
Romania
4. -Department of Surgery II, Clinic of Plastic and Reconstructive Surgery, ''Victor Babes'' University of Medicine and
Pharmacy, Timisoara, Romania
5. - ''Austria House'', Clinic of Plastic and Reconstructive Surgery, Emergency County Hospital, Timisoara, Romania
Correspondence to:
Horia Pleº, Department of Neurosciences, Clinic of Neurosurgery,
''Victor Babes'' University of Medicine and Pharmacy,
2, Eftimie Murgu Square, 300041 Timisoara, Romania.
E-mail: [email protected]
206
INTRODUCTION
The right subclavian artery (RSA) arises from the
brachiocephalic trunk, behind the upper border of thr right
sternoclavicular joint, ascend above the clavicle. This
trunk ascends at first above the clavicle superomedial,
and then posterior to scalenus anterior muscle, and
second descends laterally to scalenus anterior, to the
outer border of the first riv, where they continue to right
axillary artery. From the upper wall of initial part of the
vertebral artery, arises the vertebral artery. Lateral of
vertebral artery origin, from the upper wall of the RSA
close to the medial border of the scalenus anterior
originated the thyrocervical trunk; this trunk divided into:
the inferior thyroid, the suprascapular, and the transverse
cervical arteries. At the same level, from the lower wall of
RSA arises the internal thoracic artery. The subscapular
artery, the largest branch of the axillary artery, arises
from the 3rd part of this artery, in relation with the lower
border of the subscapularis muscle, and forking in
thoracodorsal and circumflex scapular artheries [1-4].
Two aspects of pathology are more common in right
subclavian artery: the subclavian steal syndrome and the
retro-esophageal subclavian artery (arteria lusoria). In the
subclavian steal syndrome, stenosis of the subclavian
artery proximal to the origin of the vertebral artery, in
which the blood supply to the arm is sustained by
reversal of flow in the ipsilateral vertebral artery [5, 6],
with a prevalence as between 0.6% to 6.4% [7, 8]. The
retro-esophageal subclavian artery (arteria lusoria)
passes behind the esophagus and it can compress,
causing dysphagia lusoria [9]. Early report of Myers et al.
[10] reveal that the arteria lusoria is the most common
aortic arch anomaly, occuring in 0.5-2.5% of individuals.
Studies of Wise [11] and Jusufovic et al. [12] reveal that
the cervical rib, (supernumerary rib) arising from the 7th
cervical vertebra, is a congenital abnormality that occurs
in less than 1% of the population. In the majority of cases
(73%) the cervical ribs represent predisposing factor for
subclavian artery thrombotic disease [13]. The
compression of the subclavian artery in the interscalene
triangle (part of thoracic outlet syndrome) can lead to
partial or total obliteration of the subclavian arterial blood
flow. Arterial thoracic outlet syndrome is the least
common accounting for no more than 1% [14].
Here, we report a rare variant of the distal right
subclavian artery occlusion at the level and distal of the
interscalene triangle, with formation of a collateral
parways in the vicinity of the shoulder joint between
suprascapular and dorsal scapular artery (proximal), and
207
subscapular artery (distal),
angiography.
highligted by MDCT
CASE REPORT
We report a 69-year-old male who presented to the
Neuromed Diagnostic Imaging Centre with peripheral
vascular disease of the upper right limb. Using MDCT
angiography (64-slice MDCT system; SOMATOM
Sensation, Siemens Medical Solutions, Forchheim,
Germany), the patient was found to have a distal right
subclavian artery occlusion. The reconstructed image
datasets were transferred to Syngo MultiModality
Workplace, Siemens Medical Solutions offline
workstation for post-processing. The branching pattern
of the upper limb, with the subclavian occlusion and
periscapular arterial collateral pathways were analyzed
as
3D
volume-rendering
technique
(VRT)
reconstructions, and 3D maximum-intensity projection
(MIP) reconstructions. VRT and MIP examinations clearly
highlight the location of the subclavian artery occlusion,
located in relation with the superior face of the first right
rib, with a length of 25.5 mm. The proximal end of the
subclavian occlusion has an endoluminal diameter of 5.9
mm, and the distal end has an endoluminal diameter of
5.1 mm.
The thyrocervical trunk arises form the superior wall of
the subclavian artery at 20 mm distal to the origin of the
right vertebral artery, and to 3.7 mm proximal to the
proximal end of the subclavian occlusion. With an
endoluminal diameter at origin of 2.1 mm near the origin
gives rise to the inferior thyroid artery, and after 58 mm
forking in the suprascapular, and the transverse cervical
arteries; dorsal scapular arteries arise close to origin of
the transverse cervical artery. The subscapular artery
with an endoluminal diameter at origin of 1.9 mm, arises
from the first part of the axillary artery, at 92.5 mm distal
to the origin of the thyrocervical trunk, and to 67.4 mm
distal to the distal end of the subclavian occlusion. After
51 mm from the origin, the subscapular artery is forking in
thoracodorsal artery and circumflex scapular artery. At
the level of infraspinous fossa the subscapular artery
branch profusely and connects with branches of the
suprascapular and dorsal scapular arteries. These
anastomoses partcipate to achieve the collateral
pathways of proximal portion of subclavian artery and
axillar artery.
After diagnosis of the occlusion or the right subclavian
artery at the level of interscalene triangle patient was
oriented to achieve percutaneous transluminal
angioplasty.
Fig.1. MDCT angiography of the the right shoulder, upper chest
and proximal portion of the arm, emphasizing the subclavian
artery occlusion at the level of interscalene triangle and at the
level of superior face of first right rib.
A and C - 3D volume-rendering technique (VRT): B and D - 3D
maximum-intensity projection (MIP) reconstructions. Anterior
aspect.
1.Vertebral artery; 2.Proximal part of sublavian artery; 3.Right
clavicle; 4.Thyrocervical trunk
Fig.2. MDCT angiography of the the right shoulder, and
subclavian-axillar arterial shaft. A – posterior, B – left posterior,
C – right anterior and D – superior-posterior 3D
volume-rendering technique (VRT).
1.Occluded part of subclavian artery; 2.Proximal part of
sublavian artery; 3. Thyrocervical trunk; 4.Suprascapular
artery; 5.Dorsal scapular artery; 6.Axillar artery; 7. Subscapular
artery.
DISCUSSIONS
The interscalene triangle is limited: anteriorly by the
anterior scalene muscle, posteriorly by the middle
scalene muscle and inferiorly by the first rib. The
elements of the brachial plexus and subclavian artery can
be compressed at this level, causing specific symptoms.
An extensive study of Vinson [15] sums the congenital
and traumatic factors of occurrence the compression in
the interscalen triangle:
n congenital factors: cervical rib, rudimentary first rib,
scalene muscle abnormalities, fibrous bands, bifid
clavicle, first rib exostosis, enlarged C7 transverse
process, omohyoid muscle abnormalities,
anomalous transverse cervical artery, postfixed
brachial plexus and flat clavicle.
n traumatic factors: fractured clavicle, humeral head
dislocation, upper thorax crush injury, sudden effort
of shoulder girdle muscles, and c-spine
injuries/cervical spondylosis.
A topographical description of the subclavian artery
path highlights three distinct portions: prescalenic with
the origin of the vertebral, internal thoracic artheries and
tirocervical trunk, interscalenic and postscalenic part to
continue with axillary artery. Two are clinical entities
subclavian artery obstructive affecting blood flow to the
upper limb: the first is the subclavian steal syndrome, by
subclavian artery occlusion proximal vertebral artery
origin [16, 17], and the second is the thoracic outlet
syndrome, by subclavian artery occlusion at the level of
the interscalen triangle [18, 19].
Treaties and atlases of anatomy [1-3, 20], shows
arterial anastomotic system between pre-and
retroscalenic portion of the subclavian artery, formed on
one side of suprascapular artery (satellite of the upper
edge of the scapula) and deep branch of transverse
cervical artery (dorsal scapular artery) (satelite of the
medial and lateral edge of the scapula), and on the other
side of the humeral circumflex arteries and circumflex
scapular artery from subscapular artery). At level of
infraspinous fossa is evident an anastomotic network
between the branches of suprascapular, dorsal scapular
artery and circumflex scapular artery.
In our case, the deep branch of transverse cervical
artery (dorsal scapular artery) descended only to the
upper part of the infraspinous fossa, and circumflex
scapular artery descended only to the upper one third of
the lateral edge of the scapula. The trunk in this artery
forks in into two branches: a superior branch that
connects with the suprascapular artery, and an inferior
208
branch that connect with the dorsal scapular artery.
Considering that the thyrocervical trunk arises to 3.7 mm
proximal to the proximal end of the subclavian occlusion,
extension of subclavian occlusion may affect the
permeability of these trunk and compromised the arterial
anastomotic system between pre-and retroscalenic
portion of the subclavian artery. Also any prolonged
compression or major traumatisms at the level of the
infraspinous fossa may compromise the anastomotic
system.
CONCLUSIONS
Occurrence of the distal right subclavian artery
occlusion is a rare condition. The location of the origin of
the thyrocervical trunk proximal, and the origin of the
subscapular artery distal to the level of subclavian
occlusion, promotes achievement of collateral pathways
allowing for upper limb arterial input if the subclavian
artery occlusion at the level of the interscalene triangle.
The peculiarities of this case reveal that the collateral
pathways is located at the level of superior part of the
level of infraspinous fossa.
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