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A 55 year old right handed man presented with a three month history of left arm pain and precordial chest discomfort. His symptoms had started three months previously after a heavy game of squash. Three years before the acute episode, he was involved in a motorcycle accident and had sustained a left mid-clavicular fracture.
On clinical examination he was in sinus rhythm and the supine blood pressure was 146/94 mm Hg in the right arm. He had a cold left arm with no recordable blood pressure. The left axillary, brachial, and radial pulses were absent. A bruit was audible over the left subclavian artery. The fasting total cholesterol was 4.4 mmol/l.
The chest radiograph showed non-union and displacement of the fragments of the left clavicle. Three dimensional contrast enhanced magnetic resonance angiography (CE-MRA) showed a small false aneurysm (diameter 1.5 cm) in the mid-portion of the left subclavian artery (see fig 1). In addition there was a stenosis of the left subclavian artery adjacent to the aneurysm with an intraluminal thrombus, immediately distal to the point of stenosis. The aneurysm probably resulted from insult to the subclavian artery by the clavicular fracture and aggravated by squash playing.
Percutaneous balloon angioplasty with stent deployment to the left subclavian artery was attempted. The procedure was complicated by acute thrombosis in situ, requiring intra-arterial thrombolysis with streptokinase. Restoration of blood flow was achieved by a reverse vein graft bypass between thoraco-acromial and brachial arteries.
Injury to the subclavian artery should be considered in all patients who complain of ischaemic symptoms in the arm after clavicular fracture. Furthermore, this case highlights the importance of CE-MRA as a quick and accurate non-invasive diagnostic tool in evaluating abnormalities in the peripheral vasculature.