axillary artery clot

Thursday, May 11, 2017

This is the story of Jeurys Familia, the 27-year-old pitcher for the New York Mets. After pitching poorly and coaches concern about the power and velocity of his pitches, he was off to the doctor who found a blood clot in his axillary artery that is the main supply of blood to his pitching arm.

Blood clots in an artery are supposed to happen in patients who have longstanding risk factors for atherosclerosis, including high blood pressure, high cholesterol, diabetes and smoking. Plaque, a waxy, cholesterol deposit builds up on the inside of the artery wall causing it narrow. If that plaque ruptures, the artery can be completely occluded by a thrombus (clot) and blood supply is lost beyond the obstruction. This is the mechanism that causes a heart attack or stroke. The situation is a medical crisis and the patient or family needs to recognized the symptoms so that patient can get emergency care to open the blocked artery and restore blood flow.

Young, elite athletes aren’t supposed to develop arterial blood clots. Being young and healthy is protective for diseases of old age, except there are other reasons for an artery to narrow, and when it does, blood flow can slow enough to form the begins of a blood clot that can slowly grow and impeded blood flow. There are a couple of case reports in the medical literature that explain why pitchers can develop clots in their throwing arm.

A pitcher puts plenty of torque on the shoulder with each overhead throw of a ball and if the muscles, tendons, and ligaments can’t keep the shoulder joint stable, overtime it will become lax or a little loose. Studies o show that after 50 throws, pitchers with shoulder laxity have slower and less blood flow than a pitcher with normal shoulder anatomy and function. These studies show that part of the axillary artery gets compressed with each throw and then gradually recovers between pitches.

As the arm is abducted, or raised up away from the body, there is less black dye flowin the artery

Over time, the risk of clot formation increases but symptoms are vague and can be misinterpreted as being caused by nerve compression. Athletes will present with complaints of cold intolerance, hypersensitivity, pain, numbness, or arm fatigue during or immediately after practice and competition. And this may be a reasonable alternative diagnosis since the nerves to the arm pass right next to the axillary artery in the armpit. Nerve damage was the cause of the pain and numbness of another Mets’ pitcher, Matt Harvey, whose problem was due thoracic outlet syndrome, where a rib pressed onto the nerve. He required surgery to remove part of the rib to make room for the axillary artery and nerve to pass into the arm.

But physical examination should detect a cooler hand or arm that may be slightly discolored and pulses may be difficult to feel at the wrist. Those would be classic finding, but many patients don’t read the textbook and physical findings may resolve relatively quickly if the axillary artery opens enough on its own after being in spasm. The finding may be missed by the trainer or doctor if the physical exam happens after the symptoms have resolved. As the artery further narrow, symptoms persist longer and longer, until they are more obvious and the artery more compromised with increase clot formation.

It’s still early in Mr. Familia’s assessment to decide what treatment will be required. Imaging of the shoulder joint (likely MRI) and the arteries (CT angiography) will need to be done to look at the anatomy of the shoulder and blood vessels and assess the blood flow to the arm. If the axillary artery is scarred, then the damaged part of the artery needs to be cut away and replaced. While it may take weeks to allow the area to heal, if blood flow is re-established to normal levels, the goal will be to allow him to throw again at the major-league level.

The lesson to be learned is that symptoms that might be from artery damage or occlusion shouldn’t be ignored, whether it is a heart attack and chest pressure/pain, or a stroke with weakness, slurred speech and confusion or an arm that turns a little blue and hurts.




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