Assessment and Treatment of Recurrent/Residual ATOS

Recurrent ATOS is uncommon and can be limb threatening. It can be due to several causes including failure to recognize arterial pathology when excising cervical or anomalous first ribs, failure to recognize an abnormal rib when repairing subclavian artery pathology, thrombosis of a subclavian artery or a previous arterial repair, or development of stenosis in a previously repaired subclavian artery. Patients may present with arm and hand claudication or acute upper limb ischemia caused by graft thrombosis or distal emboli. Depending on the etiology, treatment may include excision of an abnormal rib, thrombectomy or replacement of the subclavian artery or previous bypass graft, or distal embolectomy. In addition, the potential contribution of sympathetic nerves to the ischemic condition should be evaluated and addressed.