Upper-Limb Ischemia Due to Distal Embolization from a Dissecting Axillary Artery Pseudoaneurysm in an Elite Overhead Athlete: A Case Report

Abstract

In overhead-throwing athletes, repetitive shoulder motion may cause intimal injury and pseudoaneurysm formation, most commonly involving the posterior circumflex humeral artery. An elite cricket fast bowler in his 20s presented with 6 months of left shoulder and hand discomfort, followed by rest pain and numbness of the fourth and fifth fingers. Duplex ultrasonography showed thrombosis of an axillary artery pseudoaneurysm with distal radial and ulnar artery embolization, and magnetic resonance imaging demonstrated a 1.5-cm pseudoaneurysm at the origin of the subscapular artery. Surgical exploration revealed a spiral intimal dissection with organized thrombus. The pseudoaneurysm was excised, the intima was secured with tacking sutures, the axillary artery was repaired with a great saphenous vein patch, and thromboembolectomy was performed. The patient returned to work at 6 months without residual deficits. Delayed diagnosis may compromise limb salvage and functional recovery. Early recognition of vascular pathology is essential in overhead athletes.

INTRODUCTION

Upper-limb ischemia in young athletes is uncommon but potentially limb-threatening and can result from repetitive overhead activities that cause vascular injury. These activities in sports such as cricket expose the axillary artery and its branches to compression, traction, and shear stress during abduction and external rotation. This can lead to intimal hyperplasia, arterial dissection, thrombosis, and aneurysm or pseudoaneurysm formation, with subsequent distal thromboembolism [1-3]. Although such injuries have been well described in baseball and volleyball players, they have rarely been reported in cricket players. The clinical presentation is often subtle and may mimic musculoskeletal conditions, leading to missed or delayed recognition. Early diagnosis is critical because delayed intervention may allow progressive thrombosis and distal embolization, thereby threatening limb viability and functional recovery [4].

We report a case of an axillary artery pseudoaneurysm with distal embolization in a professional cricket bowler, highlighting the diagnostic challenges and management considerations. Consent was obtained from the patient, and no identifying information is disclosed in this report.

CASE

A young male, in his 20s with no known comorbidities, presented with left shoulder and hand discomfort that had persisted for 6 months. He was a professional cricket fast bowler and had undergone arthroscopic repair of a left rotator cuff tear 7 years previously. His discomfort acutely worsened during exercise and was relieved at rest. He had managed the symptoms conservatively with analgesics; however, during the preceding 2 weeks, he developed numbness in the fourth and fifth fingers along with rest pain, prompting him to suspend his daily endurance training and routine practice.

On physical examination, the left upper limb was warm, nonedematous, and nontender, with no discoloration or limitation of range of motion. A weak radial pulse was palpable in the neutral sitting position but disappeared during Adson’s maneuver, raising suspicion of thoracic outlet compression. The left ulnar pulse was not palpable, whereas it was normal on the contralateral side. Both brachial pulses were palpable. Sensory examination, muscle strength, capillary refill, and hypermobility tests were within normal limits. The right arm was normal with no ulceration or splinter hemorrhage. Based on these findings, a provisional diagnosis of subacute left upper-limb ischemia was made.

Left upper limb arterial duplex ultrasonography revealed aneurysmal dilatation of the axillary artery with thrombosis and partial embolic occlusion of the distal radial and ulnar arteries. The anatomical location of the lesion is illustrated in Fig. 1. Furthermore, magnetic resonance imaging (MRI) of the thoracic outlet revealed a 1.5-cm pseudoaneurysm of the left axillary artery at the origin of the subscapular artery, with partial acute thrombus within the fundus of the pseudoaneurysm sac and parent axillary artery (Fig. 2). Echocardiography showed no intracardiac thrombus or vegetation and normal ventricular systolic function.

Fig. 1.

Schematic illustration of the axillary artery pseudoaneurysm at the origin of the subscapular artery, adjacent to the pectoralis minor.

Fig. 2.

Magnetic resonance angiography demonstrated a 1.5-cm pseudoaneurysm of the left axillary artery at the origin of the subscapular artery, with partial thrombosis of the fundus of the pseudoaneurysm and parent axillary artery.

After diagnosis, the patient was counseled regarding surgical exploration of the left axilla, excision of the pseudoaneurysm, thrombectomy and vein patch repair of the left axillary artery, and embolectomy of the distal arteries. The potential risks of reperfusion injury and limb loss, as well as the technical challenges associated with the narrow operative field, were explained. The operative repair is illustrated schematically in Fig. 3.

Fig. 3.

Schematic representation of operative repair. (A) An intimal flap and associated organized thrombus are shown at the arterial defect. (B) The dissected intima was secured with tacking sutures. (C) Venous patch angioplasty was performed to restore the arterial lumen.

Intraoperatively, an axillary artery pseudoaneurysm was identified at the origin of the subscapular artery and was densely adherent to the adjacent brachial nerve bundles (Fig. 4A, B); no muscle hypertrophy was observed. After dissection, isolation, and control of the axillary artery, the pseudoaneurysm was dissected and excised. Inspection of the axillary arterial defect revealed a 1.5-cm spiral intimal dissection of the anterior wall with organized thrombus within the subintimal space (Fig. 4C). After removal of the organized thrombus, the dissected intima was secured with 7-0 Prolene tacking sutures, and the arteriotomy was closed using a longitudinal onlay venous patch harvested from the left great saphenous vein. Proximal and distal thromboembolectomy was performed through the brachial artery via an antecubital incision using a 3-Fr Fogarty catheter, thereby avoiding further manipulation of the dissected axillary artery intima. Good inflow and backbleeding were obtained, with no residual thrombus.

Fig. 4.

Intraoperative findings. (A) The axillary artery pseudoaneurysm was exposed at the origin of the subscapular artery, adjacent to the axillary vein and brachial plexus. (B) The pseudoaneurysm neck was ligated for vascular control, the fundus was excised, and the residual sac was transfixed. (C) Arteriotomy revealed white organized thrombus within the subintimal space of the anterior arterial wall. A, artery; Ax, axillary; Br, branch; Br Px, brachial plexus.

The surgical drain was removed on postoperative day 2. The patient developed postoperative radial nerve dysfunction, manifested by weakness of wrist and elbow extension against resistance, for which physiotherapy and rehabilitation were instituted. He gradually recovered and resumed daily activities and low-intensity practice 3 months postoperatively. Postoperative arterial duplex ultrasonography showed a patent axillary artery without hemodynamically significant stenotic or occlusive lesions in the upper limb arteries. MRI demonstrated left radial nerve axonotmesis with a focal neuroma in continuity at its origin from the posterior cord. These findings indicated disruption of axonal continuity with preservation of the surrounding connective tissue framework, while the neuroma represents a localized proliferative response to nerve injury consistent with the observed neurological deficits. Follow-up duplex ultrasonography confirmed good flow in the left brachial, radial, and ulnar arteries. The patient returned to work 6 months postoperatively without residual deficits.

DISCUSSION

Cricket is a noncontact sport but involves repetitive overhead activity that can result in various overuse and impact injuries. Vascular injuries associated with overhead activity have been extensively described in baseball and volleyball players; however, reports involving cricket players remain scarce [5-7].

In 1945, Wright [6] described neurovascular compression associated with hyperabduction of the arm in a major league pitcher. The second portion of the axillary artery was occluded by extrinsic pressure from the overlying pectoralis minor. Rohrer et al. [8] demonstrated positional axillary artery compression in 83% of 92 examined arms, although greater than 50% stenosis occurred in only 7.6%. A cross-sectional survey of 99 elite volleyball players reported prevalences of individual symptoms suggestive of digital ischemia in the dominant hand ranging from 11%-27% [9]. In another ultrasound study, 13 of 280 elite volleyball players (4.6%) were found to have posterior circumflex humeral artery (PCHA) aneurysms, all involving the proximal PCHA arising directly from the axillary artery [10].

Overhead athletes may develop hypertrophy of the shoulder girdle muscles, including pectoralis minor muscles [11], thereby increasing the likelihood of compression of nearby structures and intimal injury, with subsequent thrombosis or aneurysm formation [12-14]. The pathophysiology has been hypothesized to involve shear stress causing vascular endothelial injury and smooth muscle cell proliferation, leading to post stenotic aneurysmal dilation. However, in a case series by Rollo et al. [14], all cases had dissecting aneurysms resulting in a “stump syndrome,” whereby embolic material accumulated in the cul-de-sac and was subsequently propagated into the brachial and distal arteries by repetitive mechanical forces during overhead activity.

McCarthy et al. [13] reviewed 23 athletes who presented with upper extremity arterial compromise. The patients were divided into two groups: those with arterial compression at the thoracic outlet (11 athletes) and those with hand ischemia due to repetitive trauma (12 athletes). Most were baseball players. This study demonstrated that repetitive athletic activity can lead to vascular injury through two principal mechanisms: digital or ulnar artery trauma causing hand ischemia and subclavian or axillary artery compression due to muscle hypertrophy or bony abnormalities causing thoracic outlet syndrome.

Most previously reported pseudoaneurysms in overhead athletes involved the circumflex humeral arteries. In contrast, one study reported involvement of the subscapular artery [2]. PCHA injury has been attributed to vascular quadrilateral space syndrome, which results from distraction and compression of the PCHA as it courses through the quadrilateral space. The injury is caused by repeated abduction and external rotation of the arm [14].

Irrespective of the arteries involved, dissecting aneurysms causing recurrent embolic episodes may be underdiagnosed. Diagnosis is often delayed due to the rarity of these lesions and limited clinical awareness. The presentation can be nonspecific and is mostly characterized by exercise-induced claudication, paresthesia, fatigue, ulceration, or severe Raynaud phenomenon. These symptoms may easily be misinterpreted as musculoskeletal disorders. Therefore, a high index of suspicion should be maintained in young, healthy athletes. On examination, radial or ulnar pulses may be absent, along with delayed capillary refill, poikilothermia, pallor, fingertip ulceration, or dry gangrene.

Delayed diagnosis can lead to thrombus propagation, aneurysm rupture, and recurrent embolic events, potentially converting a salvageable limb into a nonsalvageable ischemic limb [15]. Similar activity-related or compressive arterial syndromes include arterial thoracic outlet syndrome, external iliac artery endofibrosis, popliteal artery entrapment syndrome, and adductor canal syndrome [14].

Digital subtraction angiography can provide dynamic assessment of positional arterial compression and detailed evaluation of distal embolization. Arterial duplex ultrasonography is useful for evaluating distal perfusion, whereas computed tomography or magnetic resonance angiography provides detailed anatomical delineation of the thrombus extent and potential etiological factors. In cases of acute thrombosis, catheter-directed thrombolysis using tissue plasminogen activator may be considered. However, thrombolysis is less likely to be beneficial when symptoms have been present for several weeks and thrombus has become organized. Definitive management generally involves operative reconstruction of the axillary artery and treatment of distal thromboembolism. When the lesion arises from the PCHA, flush ligation and division of the PCHA may be performed, with decompression of associated muscular compression when indicated.

Complete functional recovery can be achieved within several months after timely surgical intervention and appropriate rehabilitation [1]. Surgical treatment may involve mobilization and segmental reconstruction of the affected axillary artery, ligation or excision of branch aneurysms, and concurrent management of distal thromboembolism [13].

In summary, early recognition and timely surgical intervention are essential for limb salvage and functional recovery. This case underscores the need for a high index of suspicion for vascular pathology in overhead athletes presenting with upper-limb symptoms, particularly in sports such as cricket, in which these injuries may be overlooked.

Funding Statement

FUNDING None.