Shoulder disarticulation as a result of distal subclavian artery total occlusion after radiotherapy

Abstract

The first percutaneous transluminal angioplasty (PTA) including dilatation of the occluded arteries, mechanical thrombectomy, catheter‐directed thrombolysis was completed. Throughout the patient's hospital course, ischemia‐reperfusion injury, including respiratory distress, pulmonary edema, shock, and acute kidney injury, was observed after the first PTA, and acute compartment syndrome developed the day after the second PTA. In clinical scenarios where a patient presents with symptoms of acute arterial occlusion and has exposure history of radiotherapy exceeding 40Gy around the site of interest, RIAI should be considered.

Dear Editor,

A 59‐year‐old man presented with progressively worsening left arm pain over the past 3 days. Tracing back his history, he was diagnosed with follicular thyroid carcinoma 10 years ago. He underwent radiotherapy over left lateral chest wall metastasis with the regimen consisting of 4800 cGy/12 fractions given over a 17‐day course 2 years ago. The patient complained of progressive pain, coldness, and paleness over left upper limbs over the course of 3 days, with cyanotic change over left hand fingers over the past day upon his arrival (Figure A). Physical examination revealed no palpable pulsation and loss of sensory and motor functions. In addition, radiation induced large wounds with bone exposure were also found, with one 20 × 8 cm wound over the left scapula area (Figure B).

Fig. 1. Progressively worsening ischemic change over the patient's left hand fingers were noted upon presentation. B, Large (20 × 8 cm) pressure injury over the left scapular and axillary area was noted upon presentation. C, Left upper extremity angiogram revealed total occlusion of the left distal subclavian artery. D, A third angiography revealed 90% stenosis of the left axillary artery with thrombus. Blood flow could be observed down to near the brachial artery. E, Left upper limb 3 days after the third angiography, and the patient underwent disarticulation of the left shoulder 2 days later

Left upper extremity angiogram revealed total occlusion of the left distal subclavian artery (Figure C). The first percutaneous transluminal angioplasty (PTA) including dilatation of the occluded arteries, mechanical thrombectomy, catheter‐directed thrombolysis was completed. However, sufficient improvement and patency of the occluded arteries could not be achieved. He then received second PTA 2 days later, and a third angiography 4 days afterward revealed 90% stenosis of the left axillary artery with appreciable thrombus (Figure D). Throughout the patient's hospital course, ischemia‐reperfusion injury, including respiratory distress, pulmonary edema, shock, and acute kidney injury, was observed after the first PTA, and acute compartment syndrome developed the day after the second PTA. Five days after the third angiography, we made the decision to perform disarticulation due to progressively worsening severe sepsis and left upper limb tissue necrosis (Figure E).

Thomas E. first reported on radiotherapy induced arterial injury (RIAI) presenting as stenosis or obstruction of the major great vessels. Following a relatively low dose of radiation (40‐80Gy) around the lesion, pathologic features revealed the stenotic lesion mimicking atherosclerosis. Symptomatic onset was reported to range from 6 months to decades after radiotherapy.

In our case, RIAI was our initial impression because the obstructed site of the distal subclavian artery was directly exposed to his previous palliative radiotherapy. This was further supported by pathologic examination of the marginal tissue of the disarticulated wound revealing sclerotic fibrous tissue with focal tissue necrosis and no malignant findings.

Acute and massive soft tissue necrosis or thromboembolism as an outcome of RIAI is rare, with only three cases documented in the literature. Bressler E et al. presented a case of acute right hand ischemia due to RIAI of the axillary artery following a 3‐week regiment dose of 30Gy for right axillary Hodgkin lymphoma nodes. The patient underwent thrombectomy and vein patch angioplasty. Behr B et al. reported massive arm necrosis as a result of complete right subclavian artery occlusion 34 years after mastectomy and subsequent radiotherapy. This patient was managed with PTA followed by bypass surgery. Hughes WF et al. presented a case with index finger necrosis as a result of total subclavian artery occlusion. The severity of RIAI related ischemia and consequences of our case are more prominent, and to the best of our knowledge, this is the first published report of RIAI with total occlusion of the subclavian artery necessitating major limb amputation.

In clinical scenarios where a patient presents with symptoms of acute arterial occlusion and has exposure history of radiotherapy exceeding 40Gy around the site of interest, RIAI should be considered.

CONFLICT OF INTEREST

All authors declare no conflict of interest.