Subclavian artery thrombosis is a rare cause of upper limb ischemia resulting from occlusion of the upper extremity blood supply. Possible catastrophic clinical consequences necessitate prompt rectification of the underlying disease and risk factors. Treatment modalities are often selected depending on the severity of clinical presentation The surgical treatment of subclavian artery acute thrombosis/ embolism could lead to serious complications including thrombotic incidents in the vertebro-basilar system regardless of the technique used.

Case report: 38 female patient presented with 3-day history of pale and painful fingers of the left hand. CT angiography revealed thrombotic occlusion of the left subclavian artery at the level of the vertebral artery origin, and distal thrombosis of the brachial artery bifurcation.Without signs of compression or vessel wall changes. No data of atrial fibrillation or cardiac sours of emboli was detected. We performed open embolectomy through the distal brachial artery under local anesthesia. To control the risk of embolization in the vertebral artery during thrombectomy, it was done with a temporary proximal balloon occlusion of the subclavian ostium through a femoral access. This maneuver resulted in reversed blood flow of vertebral artery. The proximal balloon was deflated after control angiography showing clear subclavian and vertebral artery. Without distal embolization.

Discussion Upper extremity ischemia due to thrombosis of the subclavian artery is quite uncommon. There is a fourfold predilection for thrombosis of the left subclavian artery as compared to its right counterpart. The presence of collateral blood supply dictates the onset of clinical symptoms. The presenting symptoms are manifestations of interrupted blood supply to the upper extremity. Generally, symptoms include muscle fatigue, arm claudication, pain at rest, and finger necrosis. The findings on pulse examination include absent or diminished axillary, radial, and brachial pulses. Other possible clinical entity in acute proximal subclavian thrombosis are connected to vertebra-basilar insufficiency but they are rare because of the double blood supply of the basilar artery.

In our case the clinical presentation was with severe symptoms of upper limp ischemia without neurological signs. Any blind thrombectomy or cathether based treatment have the potential risk of dislodgment of the thrombus and embolization in the posterior cerebral circulation.