Symptomatic axillary artery dissection in a tennis player. Case report

Retrograde dissection of the axillary artery during arteriogram via arteriovenous access

INTRODUCTION

Retrograde arterial dissection is a recognized complication of endovascular intervention but has not been well reported especially in the context of dialysis arteriovenous access procedures. The management of this complication is also not well defined.

CASE PRESENTATION

We report the case of an 80-year-old female with end-stage renal disease (ESRD) on dialysis who developed an asymptomatic retrograde dissection of the left axillary artery during an arteriogram performed via a retrograde approach as part of access dysfunction evaluation. The condition was managed conservatively with no other intervention and close follow-up. No surgical intervention or stenting was needed in this case.

DISCUSSION

Conservative management of retrograde arterial dissection in the arm may be a viable option especially in asymptomatic patients due to the nature of the injury. The force of blood flow in the antegrade direction limits the expansion of the false lumen and likely promotes the spontaneous healing of the vessel.

Axillary artery thrombosis in a baseball pitcher

Isolated nonatherosclerotic axillary artery disease is a rare condition. External axillary artery compression can result in occlusion or aneurysm formation and subsequent upper extremity ischemia or distal thromboembolism. Chronic compression from use of crutches and repetitive stretching/compression of the axillary artery secondary to overhead motion during high-performance athletic activities are often implicated as the cause. The uniqueness of these lesions and clinical setting requires a high index of suspicion for axillary artery pathology. Prompt diagnosis with arteriography and surgical treatment is necessary given the propensity for thromboembolism. We present a case highlighting this rare phenomenon in a collegiate baseball pitcher.

Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete

OBJECTIVES

To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment.

METHODS

A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management.

RESULTS

Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up.

CONCLUSIONS

Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism.

Tennis injuries: occurrence, aetiology, and prevention

A systematic search of published reports was carried out in three electronic databases from 1966 on to identify relevant articles relating to tennis injuries. There were 39 case reports, 49 laboratory studies, 28 descriptive epidemiological studies, and three analytical epidemiological studies. The principal findings of the review were: first, there is a great variation in the reported incidence of tennis injuries; second, most injuries occur in the lower extremities, followed by the upper extremities and then the trunk; third, there have been very few longitudinal cohort studies that investigated the association between risk factors and the occurrence of tennis injuries (odds ratios, risk ratios, hazard ratios); and fourth, there were no randomised controlled trials investigating injury prevention measures in tennis. More methodologically sound studies are needed for a better understanding of risk factors, in order to design useful strategies to prevent tennis injuries.

Traumatic Axillary Artery Dissection with Radial Artery Embolism

This report describes a case of pathologically proven traumatic arterial dissection, presenting as complete occlusion of the axillary artery with radial artery embolism. Occlusion of the axillary artery by traumatic dissection mimicked transection and radial artery embolism mimicked congenital absence of the radial artery on the initial angiogram, but these were correctly diagnosed with the following sonogram.