Nous rapportons les observations de trois patients ayant présenté des complications artérielles graves d'un syndrome du défilé thoraco-brachial compliquant une pseudarthrose de clavicule ancienne, d'origine congénitale ou acquise. La symptomatologie artérielle initiale, d'apparition tardive dans l'évolution de la maladie, était polymorphe : claudication d'effort, ischémie sub-aiguë, ou ischémie sévère avec gangrènes digitales. Une compression artérielle par la pseudarthrose, associée à une dilatation poststénotique de l'artère sous-clavière, contenant du matériel athéromateux emboligène, était retrouvée dans tous les cas. Une résection partielle de clavicule et une résection-pontage des segments artériels sous-claviers pathologiques ont permis de revasculariser le membre supérieur, et de prévenir la récidive des complications thromboemboliques. D'autres techniques de revascularisations peuvent y être associées. D'autres étiologies claviculaires ont été décrites. Ce syndrome doit être prévenu par le traitement optimal des fractures de clavicule.

During a 3-year period, three patients developed arterial complications related to congenital or post-traumatic old pseudarthrosis of the clavicle. Arterial complications of pseudarthrosis of the clavicle presenting as a thoracic outlet syndrome are very rare. Symptoms are variable and occur late. Without treatment, the prognosis is poor with spontaneous development of gangrene. Arterial morphology investigations should be undertaken in patients with pseudarthrosis of the clavicle or isolated arterial symptoms involving the upper limb whose radial pulse disappears during postural tests. Duplex Doppler of the subclavian artery is an excellent screening exam but selective arteriography is the gold standard. It shows proximal arterial lesions (embolytic stenosis of the subclavian artery with post-stenotic dilatation), as well as distal embolic complications. Both static and postural tests must be performed to unmask subclavian restriction by the clavicle, proving its causal effect in the arterial complications.

There are four clinical varieties: chronic thrombosis of the subclavian artery, distal arterial micro emboli, acute thrombosis of proximal arteries of the upper limb, and subclavian aneurysm. These lesions are thought to be due to chronic constriction and repeated arterial microtrauma.

Congenital or post-traumatic pseudarthrosis, hypertrophic callus, arterial restriction by a screw in a clavicular plate, usually explain the arterial lesions. Bone tumors and Paget's disease are potential but exceptional clavicular etiologies.

Surgical treatment is always necessary. Clavicular resection is usually needed in case of pseudarthrosis; there is no functional handicap. Plate fixation and autologous grafting, or open reduction and internal fixation are other valid surgical treatments; The embolytic lesions must be treated to prevent recurrence of distal embolization: graft resection and thromboendarteriectomy have been described. Neurological and venous decompression may be associated at the same time. Complementary treatment can be associated: distal bypass, cervicothoracic sympathectomy, in situ thrombolysis or thrombectomy. Endovascular treatment is not indicated.

Optimal treatment of clavicular fractures is required to prevent the development of thoracic outlet syndrome.