Management of digital emboli, vasospasm, and ischemia

Unilateral digital ischemia is one of the most common presenting problems in patients with arterial TOS, leading to numbness, tingling, cold and painful sensations, cyanotic or pale discoloration, delayed capillary refill in the fingers, and non-healing fingertip ulceration. Diagnostic evaluation requires differentiation between proximal and distal arterial sources of thromboembolism, localized digital artery occlusion, and primary vasospasm (Raynaud's disease). Digital emboli typically accompany arterial TOS as a result of mural thrombus formed within an area of aneurysmal degeneration in the subclavian (or axillary) arteries. While there are a variety of medical treatments to help reduce local symptoms of digital ischemia and vasospasm, definitive management depends on surgical control of the proximal source of thromboembolism. Additional interventions, such as thromboembolectomy, intra-arterial infusion of thrombolytic agents and/or vasodilators, cervical sympathectomy or periarterial digital sympathectomy, and injections of botulinum toxin to the hand, are all valuable adjuncts toward achieving optimal outcomes.