Axillary artery thrombosis

Background

Axillary artery thrombosis may occur secondary to multiple mechanisms:

• Thoracic outlet compression from cervical ribs, anomalous fibrous bands, or scalene muscle hypertrophy
• Abduction and external rotation of the upper extremity resulting in compression, contusion, and subsequent thrombosis of the artery by the humeral head [such as in baseball pitchers]
• Distal embolization, such as from an aneurysmal subclavian artery
• The second portion of the artery may be compressed and occluded by the pectoralis minor [“hyperabduction syndrome”]
• Sequela of direct arterial injury [such as penetrating injuries, displaced humeral neck fractures, arterial intimal tears]
• Rarely, anterior shoulder dislocation may lead to thrombosis
• Improper use of crutches may cause axillary artery aneurysm and subsequent thrombosis

Anatomy

• Continuation of the subclavian artery
• Defined by the lateral border of the first rib to the inferior border of teres major muscle
• Continues as the brachial artery
• Axillary vein runs medial to the artery

Clinical Features

• Symptoms of vascular insufficiency:
  • Fatigue of the extremity
  • pallor
  • poikilothermia
  • pain
  • paraesthesias
  • pulselessness/diminished pulses (radial, ulnar)
• Blood pressure discrepancy between the upper extremities

Differential Diagnosis

• Arterial compression without thrombosis
• Thrombosis proximal or distal to the axillary artery
• Arterial dissection
• Vasculitides

Physical Exam

• Examination findings of vascular insufficiency (see above)
• Pulse discrepancy between upper extremities
• Blood pressure discrepancy between upper extremities
• May require Doppler to detect pulse
• Potentially, distal ischemic infarcts from thrombus embolization

Workup

• Labs: Coagulation studies
• Imaging: Duplex scan, Arteriography

Management

• Vascular Consult:
• Direct thrombolysis followed by oral anticoagulation
• Surgical exploration may be indicated

Disposition

• Admit

Complications

• Distal ischemia of upper extremity (neurovascular compromise)
• Distal embolization of thrombus
• Compartment syndrome of upper extremity

See Also

• Paget-Schroetter syndrome
• DVT
• Superior vena cava syndrome

References

• Rohrer, Michael J. et al. Axillary artery compression and thrombosis in throwing athletes. Journal of Vascular Surgery, Volume 11, Issue 6, 761 – 769.
• Hayes JM, Van Winkle GN. Axillary artery injury with minimally displaced fracture of the neck of the humerus. J Trauma. 1983 May;23(5):431-3.
• Duwayri, Yazan M. et al. Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete. Journal of Vascular Surgery, Volume 53, Issue 5, 1329 – 1340.
• Popescu, D., et.al. Axillary arterial thrombosis secondary to anterior shoulder dislocation. Acta orthopaedica Belgica (Impact Factor: 0.65). 11/2006; 72(5):637-40.
• Wheeless, C.R. Axillary Artery. Wheeless’ Textbook of Orthopaedics. Last updated 12/15/11. <http://www.wheelessonline.com/ortho/axillary_artery>