Digital ischaemia of the upper limbs in middle age: consider arterial thoracic outlet syndrome until proven otherwise !

Objectives Patients presenting with digital upper limb ischaemia are occasionally referred to rheumatology services to rule out vasculitis. We present two cases of delayed diagnosis of arterial thoracic outlet syndrome (TOS) in middle aged patients presenting with digital ischaemia in order to raise awareness of this important pathology that requires timely surgical intervention. Methods Two cases of progressive ischemia of the right upper extremity caused by primarily undiagnosed compression of the subclavian artery (SCA) by an accessory cervical rib are presented. Both patients case notes, radiological images, intra-operative and postoperative findings were reviewed. Patients were followed up after at least 6 months to assess prognosis. Results Both patients had working diagnosis of Buerger’s disease and treated with prostaglandin infusions prior to establishment of the diagnosis of arterial thoracic outlet syndrome. Both patients were heavy smokers and one patient had bilateral symptoms and history of axial spondyloarthropathy and positive HLA-B27. Surgical thrombectomy of the upper limb arteries along with resection of a cervical rib and repair of the SCA with interposition graft were necessitated to successfully heal digital ulcers in one patient. However, late presentation in the second patient led to the loss of three fingers and the need of plastic reconstructive surgery following cervical rib resection and revascularisation. Conclusion High index of suspicion of arterial TOS should be maintained in middle aged patients presenting with digital or upper limb ischaemia even in presence bilateral symptoms or relevant risk factors of other diagnoses such as smoking or positive rheumatological history.