Case Illustration:
A 37-year-old man with a past medical history of pulmonary sarcoidosis, melanoma in remission, and former tobacco smoking presented with recurrent pressure-quality left chest discomfort with radiation to neck and shoulder, accompanied by left arm numbness and tingling, intermittently aggravated by shoulder movement. Physical examination revealed tenderness along the medial scapula, reduced abduction of the left shoulder, minimal pain with impingement testing including Neer and Hawkins exam, negative cross-body and O’Brien’s exams (Table 1). Complete blood count, comprehensive metabolic profile, and cardiac biomarkers were normal. Cardiac work up was negative, including electrocardiogram and stress echocardiogram. Computed topography of chest and abdomen showed noncompressive lung and liver lesions, in keeping with known sarcoidosis. Magnetic resonance imaging (MRI) of cervical spine, shoulder, and brachial plexus were negative. His symptoms failed to improve with physical therapy.
A vascular duplex of left upper extremity was performed showing compression of both the subclavian vein and artery. The subclavian vein was assessed with color and spectral Doppler in the neutral position, at 90° abduction, and at 180° abduction. At both 90° and 180° abduction, there was loss of cardiac pulsatility and respiratory phasicity, but continuous flow remained, indicating compression without obstruction (Figure 1). Halstead maneuver was also performed to illicit obstruction (Table 1). This position is performed by adopting a military posture with the arms pulled back and chest protruded forward. There is complete flow obstruction provoked by this maneuver (Figure 2). Interrogation of the subclavian artery was performed with shoulder abduction and Halstead maneuver. Diminished peak systolic velocities and pulse volume recordings with provocation indicate arterial compression (Figures 3 and 4).
The patient failed conservative therapy, including non-steroids anti-inflammatory drugs (NSAIDS), Lidocaine patch, and physical therapy. He underwent left thoracic outlet decompression with trans-axillary resection of the first rib and division of the anterior scalene muscle (Figure 5). Three months after surgery, he had drastic improvement in symptoms with near complete resolution.