|Year : 2022 | Volume
| Issue : 4 | Page : 316-318
Subclavian artery thrombosis post modified radical mastectomy surgery - A rare case report
Sheikh Saif Alim, Ahmad Ammar, Mayank Yadav, Syed Shamayal Rabbani, Surbhi Chawla, Abu Shama, Mohd Azam Haseen
Department of Cardiovascular and Thoracic Surgery, JNMCH, AMU, Aligarh, Uttar Pradesh, India
|Date of Submission||30-Dec-2021|
|Date of Acceptance||03-Mar-2022|
|Date of Web Publication||8-Nov-2022|
Sheikh Saif Alim
Department of Cardiovascular and Thoracic Surgery, JNMCH, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Subclavian artery thrombosis is a relatively rare and unheard complication postmodified radical mastectomy (MRM) surgery and it is still not reported in the literature. We report a case of a 55-year-old female who underwent MRM for Stage II left ductal carcinoma of breast with level 2 lymph node involvement in a private hospital. She developed ischemic pain in the left upper limb on postoperative day 3. She came to JNMCH and was referred to us and initial imaging with computed tomography angiography revealed occlusion from the origin of the subclavian to axillary artery. We discuss the management of the aforementioned condition in our setup and would also discuss the steps needed to avoid the same in the future.
Keywords: Axillary dissection, modified radical mastectomy surgery, subclavian artery, thrombosis
|How to cite this article:|
Alim SS, Ammar A, Yadav M, Rabbani SS, Chawla S, Shama A, Haseen MA. Subclavian artery thrombosis post modified radical mastectomy surgery - A rare case report. Indian J Vasc Endovasc Surg 2022;9:316-8
|How to cite this URL:|
Alim SS, Ammar A, Yadav M, Rabbani SS, Chawla S, Shama A, Haseen MA. Subclavian artery thrombosis post modified radical mastectomy surgery - A rare case report. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Nov 28];9:316-8. Available from: https://www.indjvascsurg.org/text.asp?2022/9/4/316/360539
| Introduction|| |
Arterial occlusive diseases are uncommon delayed complications of surgery for underlying malignancies. We report a woman who presented with intermittent left upper limb discomfort, weakness, paresthesia, and acrocyanosis due to rare intraoperative vessel wall injury leading to thrombus formation from the origin of subclavian artery up to axillary artery which required a bypass grafting from proximal subclavian to brachial artery.
| Case Report|| |
A 55-year-old woman presented in our emergency with a history of left upper limb discomfort, weakness, paresthesia, and acrocyanosis of fingers. She was a case of Stage 3 infiltrating ductal carcinoma of the left breast with regional level 2 lymph node extension, and she underwent a left modified radical mastectomy (MRM) with axillary lymph node dissection. On postoperative day 3, symptoms were present at rest and with activity. She noted intermittent paresthesia of her entire hand with sensory loss, slowly progressive arm weakness, and intermittent bluish discoloration of the fingertips of left hand.
Physical examination demonstrated a prominent right supraclavicular systolic bruit. Blood pressure was 136/90 mmHg in her right arm and 88/56 mmHg in her left arm. Left radial, ulnar, brachial, and subclavian pulses were greatly reduced compared to the right. All other pulses, including the carotid, femoral, popliteal, and dorsalis pedis, were normal and without bruits. Acrocyanosis of the fingertips of all fingers and thumb of her right hand was noted. Findings on a cranial nerve examination were normal with no Horner syndrome. Motor examination showed mild weakness of her right external rotators, pronator teres, triceps, and wrist extensors. Mild atrophy of her right supraspinous muscle was evident. Her right brachioradialis and biceps reflexes were reduced. Findings on a sensory examination were revealed loss of sensation over the dorsum of hand, along the wrist and lateral border of forearm up to elbow.
Routine laboratory studies demonstrated an elevated total cholesterol level of 256 mg/dL and a low-density lipoprotein level of 128 mg/dL. Noninvasive vascular tests indicated vascular compromise to the left upper extremity. Systolic blood pressure indexes were decreased, and continuous-wave Doppler ultrasonographic signals were abnormal, indicating obstructive arterial disease at the level of the subclavian artery. Upper arm exercise produced a further decrease in her right arm systolic pressure and was associated with symptoms of arm fatigue. Thoracic outlet maneuvres were mildly abnormal, suggesting additional dynamic arterial compression at the thoracic outlet level. Cervical spine X-ray films showed no evidence of an anomalous cervical rib. A chest X-ray film revealed no significant abnormality. Echocardiography revealed no significant cardiac abnormality. Computed tomography arteriography of the aortic arch and the left upper extremity revealed irregular stenosis at the origin of the right subclavian artery, with a thrombus at the subclavian-axillary junction and irregular luminal narrowing throughout the axillary artery [Figure 1].
The clinical findings and supporting investigations indicated subclavian artery thrombosis involving the left subclavian and axillary arteries with no evidence of tumor infiltration or recurrence. Her intermittent acrocyanosis was believed to be the result of recurrent microemboli from the ulcerated plaque. Emergency surgical revascularization was planned, and initially, left brachial embolectomy was done but we were unable to negotiate the Fogarty catheter beyond axillary artery. The arterial flow was not adequate through brachial, so later, a subclavian to brachial bypass was done.
We exposed the proximal subclavian artery just below the mid part of clavicle [Figure 2].
We then took a ringed polytetrafluoroethylene graft and anastomosed the proximal left subclavian artery with mid part of left brachial artery. The arterial flow was adequate through the bypassed segment, and good Doppler signals were achieved in distal brachial, radial, and ulnar arteries. Postoperative recovery was uneventful, and the patient was discharged on postoperative 4 days.
| Discussion|| |
MRM is one of the main surgical treatments for breast cancers, in which the purpose to thoroughly eliminating breast cancer is achieved by removing the lesions and adjacent tissues of breast cancer. MRM is usually applied to patients with Stage I and II breast cancers, especially in patients with lesions distributed in the lateral breast and patients with axillary lymph node metastases. However, in MRM, the entire breast tissues are removed, the wound is relatively large, the shape of the patient is seriously damaged because of which some of the patients cannot accept such change, the psychological state of the patient is affected leading to the deterioration in postoperative quality of life.,,
Axillary artery injury sometimes rarely occurs during axillary dissection in MRM. Platelets accumulate at the site of vascular injury and are involved in many physiological and pathophysiological processes, including hemostasis and thrombosis., Binding of adenosine diphosphate and thromboxane A2 to their receptors (P2Y1 and P2Y12 and thromboxane receptor, respectively) induce aggregation of platelets., The (von Willebrand factor [vWF]) also plays a crucial role in hemostasis through adhesion and spreading of platelets.,,,,, vWF binds to platelet glycoproteins Ibα and αIIbβ3, and subendothelial collagens, which induces platelet aggregation. Platelets interact with collagen through glycoprotein VI and α2 β1, leading to platelet activation, spreading, and secretion, which in turn leads to thrombus formation.
| Conclusion|| |
Axillary artery injury during axillary dissection is a very rare complication during MRM. It has serious outcomes leading to ischemic changes in the involved limb. Careful dissection is usually advised during nodal dissection in the axilla. Hence, it is usually advised to start prompt antiplatelet therapy if any vascular injury occurs during the course of surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]