Upper extremity ischemia in athletes.

Arterial injury is infrequent in the thoracic outlet syndrome but must be identified to prevent these younger patients from being dramatically disabled. This requires thorough interview and clinical examination, and then pursuit with a workup including complete bilateral arteriography with positional views. Helical computed tomography (CT) provides precise localization of arterial trauma with correlation to specific compressive elements. Unique features in athletes include a greater role of soft tissue hypertrophy and overuse in pathogenesis of arterial injury, more frequent compression of the axillary artery and its branches, and possible hand ischemia from direct trauma. In addition, these prospective or established professionals require optimum arm function to sustain their careers. Because of the desire to continue provocative arm use, decompression is performed early, and arm "claudication" is surgically treated. Operations are customized to achieve adequate decompression without compromising function. Surgical management consists of targeted resection of compressing structures, which is most often a cervical rib; arterial reconstruction to eliminate stenosis and the source of emboli; and improvement of distal perfusion with selection from an arsenal that includes catheter embolectomy, thrombolysis, and bypass grafting. Familiarization with the many unique diagnostic aspects and therapeutic options in arterial thoracic outlet syndrome produces excellent results in all but the most advanced cases.