Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete Yazan M. Duwayri,

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Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete Yazan M. Duwayri, MD, Valerie B. Emery, RN, Matthew R. Driskill, MSPT, Jeanne A. Earley, PT, MHS, Rick W. Wright, MD, George A. Paletta, MD, Robert W. Thompson, MD Journal of Vascular Surgery Volume 53, Issue 5, Pages 1329-1340 (May 2011) DOI: 10.1016/j.jvs.2010.11.031 Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 1 Pathogenesis of axillary artery lesions and patient population. A, Compression of the third portion of the axillary artery by anterior displacement of the humeral head during the overhead throwing motion. The axillary artery is relatively fixed in position at this site by the overlying fascia, branch vessel origins, and the pectoralis minor muscle. Repetitive compression can lead to intimal hyperplasia with stenosis, or aneurysm formation, with or without thrombotic occlusion. Similar lesions may also arise in the adjacent axillary artery branches (subscapular and circumflex humeral arteries). (Drawing by Ms. Vicki Friedman, MedPIC, Washington University School of Medicine.) B, Distribution of 572 consecutive patients undergoing primary operative treatment for TOS at Washington University/Barnes-Jewish Hospital from January 2000 through August 2010. The subset of patients with arterial TOS involving the subclavian and axillary arteries is indicated. Journal of Vascular Surgery 2011 53, 1329-1340DOI: (10.1016/j.jvs.2010.11.031) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 2 Axillary artery thrombosis. A-D, Initial arteriogram demonstrating occlusion of the right axillary artery in a 29-year-old baseball pitcher (A). Surgical exploration through an upper arm incision (B), revealing acute thrombosis of the distal axillary artery (C), superimposed on an area of intimal thickening caused by focal intimal hyperplasia. The excised arterial segment was replaced by an interposition vein graft, illustrated on a completion arteriogram (D). Journal of Vascular Surgery 2011 53, 1329-1340DOI: (10.1016/j.jvs.2010.11.031) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 3 Axillary artery thrombosis and distal embolism. Magnetic resonance arteriogram in a 24-year-old baseball pitcher, demonstrating segmental occlusion of the distal right axillary artery (A). Operative exploration revealed acute thrombosis (B). The thrombus was removed (C), revealing a smooth luminal surface with a focal intimal web-like stenosis (D). This intimal lesion was resected, allowing repair with a saphenous vein patch angioplasty (E). Completion arteriography demonstrated a widely patent axillary artery repair with the arm at rest (F), and in elevation (G). Concomitant embolic occlusion of the distal brachial and ulnar arteries (H), treated by direct thrombectomy, intra-arterial thrombolysis, and vasodilator infusion. A follow-up arteriogram 6 weeks after surgery showed patent brachial and ulnar arteries (I). Journal of Vascular Surgery 2011 53, 1329-1340DOI: (10.1016/j.jvs.2010.11.031) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 4 Positional compression of the axillary artery. A-D, Initial arteriogram in a 33-year-old baseball pitcher demonstrating a patent right axillary artery with the arm at rest (A) but compression and axillary artery occlusion with the arm in an elevated position (B). Repeat arteriography 6 weeks after axillary artery repair with an interposition vein graft, demonstrating a widely patent vessel with the arm at rest (C) and when elevated (D). Journal of Vascular Surgery 2011 53, 1329-1340DOI: (10.1016/j.jvs.2010.11.031) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 5 Axillary artery dissection. Magnetic resonance arteriogram in a 32-year-old baseball pitcher, demonstrating dissection of the right axillary artery (A). Operative arteriography confirming axillary artery dissection with partial restriction in flow with the arm at rest (B), and positional occlusion at the level of the distal axillary artery with the arm in elevation (C). Surgical pathology (D) and histologic section (E) demonstrated extensive axillary artery dissection. Journal of Vascular Surgery 2011 53, 1329-1340DOI: (10.1016/j.jvs.2010.11.031) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 6 Axillary artery branch vessel aneurysm thrombosis. Initial arteriogram in a 37-year-old baseball coach, demonstrating occlusion of the right posterior circumflex humeral artery (A), along with multiple emboli to the interosseus and ulnar arteries (B). C-F, Initial arteriogram in a 31-year-old baseball pitcher demonstrating occlusion of the right posterior circumflex humeral artery (C), with embolic occlusion of the radial and ulnar arteries in the hand (D). Operative exploration demonstrated a branch vessel aneurysm (E), which was ligated and excised (F). Journal of Vascular Surgery 2011 53, 1329-1340DOI: (10.1016/j.jvs.2010.11.031) Copyright © 2011 Society for Vascular Surgery Terms and Conditions