Absent Radial Pulse Research Articles

Transulnar Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in a High Risk Individual With Absent Bilateral Radial Pulses

Transulnar Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in a High Risk Individual With Absent Bilateral Radial Pulses

Acute Stroke in a Girl With an Absent Radial Pulse

Acute Stroke in a Girl With an Absent Radial Pulse

Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication.

Suicide attempt via sodium pentobarbital is uncommon. A 48-year-old woman with a history of depression and prior suicide attempt was found unresponsive by her veterinarian spouse near a syringe containing pink solution. Upon EMS' arrival, the patient was experiencing apnea, hypoxemia, and miotic pupils; her blood glucose level measured 73 mg/dL. She was bradycardic and administered atropine with transient improvement in heart rate and transported to an emergency department; 2 mg of intravenous naloxone was administered without effect. She was endotracheally intubated via rapid sequence intubation. Rapid urine drug screening detected both benzodiazepines and barbiturates. The patient was transferred to an intensive care unit where she demonstrated a nearly absent radial pulse. Emergent fasciotomy to the left forearm and carpal tunnel was performed for acute compartment syndrome; “Euthasol” had been self-administered into the antecubital fossa. Expanded toxicological analysis via liquid chromatography/mass spectroscopy detected caffeine, atropine, 7-aminoclonazepam, phenytoin, citalopram, and naproxen. The patient's coma resolved over 48 hours and she was successfully extubated without complication. Emergency physicians must closely monitor patients exposed to veterinary euthanasia agents who develop central nervous system and respiratory depression, hypothermia, bradycardia, hypotension, or skin injury. Consultation with a regional poison center and medical toxicologist is recommended.

Takayasu arteritis presenting as bowel gangrene: An unusual initial presentation

A 24-year-old lady presented to the emergency department with severe generalized abdominal pain and hematochezia of 2 days. Examination revealed absent bilateral radial, brachial, and carotid pulses. Rest of the peripheral pulses were normal. A bruit was heard over bilateral carotid, subclavian, and renal arteries. X-ray abdomen showed dilated bowel loops with multiple air fluid levels. Doppler study revealed intimal thickening in bilateral subclavian and common carotid arteries along with decreased flow. Computed tomography (CT) angiography was done urgently that showed critical narrowing of the bilateral subclavian, common carotid, coeliac trunk, superior mesenteric arteries, inferior mesenteric arteries, and bilateral renal arteries. We present a case of mesenteric ischemia in a patient of Takayasu arteritis (TA) leading to bowel gangrene involving entire small and large bowel and a fulminant outcome, which is an uncommon initial presentation of TA.

Novel Fanci Mutations in Fanconi Anemia with Vacterl Association

Introduction: Fanconi anemia (FA) is associated with mutations in at least 18 genes in the FA/BRCA DNA repair pathway. Some patients with FA have features of the VACTERL association (vertebral anomalies, anal atresia, congenital heart disease, trachea-esophageal fistula, esophageal atresia, renal, and limb anomalies [radius and/or thumb]). Any three anomalies are required to be classified as VACTERL association. The presence of this association among cases with FA is considered to be 5%; the frequency of FA among those with VACTERL association is unknown.Objective: To determine the genotype in previously uncharacterized patients with FA and to examine the relationship between genotype and features of VACTERL association.Methods: The NCI FA cohort included 18 unrelated patients with the VACTERL association, among 54 FA patients who had comprehensive examinations including radiologic and ultrasound studies at the NIH Clinical Center (33%). DNA from patients with unknown genotypes was subjected to whole exome sequencing (WES) at the NCI's Cancer Genomic Research Laboratory; one patient's DNA was also studied by sequencing the coding regions of all known FA genes (Haloplex sequencing) at Vrije Universiteit.Results: Mutations in FANCI were identified in three of the 18 patients with the VACTERL association, two at the NCI and the third patient at Vrije Universiteit; there were no FANCI patients among those without the VACTERL association. Mutations in the others with VACTERL were A (N=6), C (N=4), D2 (N=2), J (N=2), and unknown (N=1).NCI-82-1 had multiple birth defects. At 5 9/12 years she had extreme short stature, microcephaly, triangular face, and VACTERL features (fused cervical vertebrae, atrial septal defect [ASD], ventricular septal defect [VSD], duodenal atresia, small kidneys, and absent thumbs). Progressive cytopenias led to stem cell transplantation at age 10 1/2 years, with death a year later from multi-organ failure. WES data identified FANCI mutations: one deletion (p.Ser1268Argfs*5) and one insertion (p.Asp1301Glyfs*3) resulting in premature stop codons.NCI-253-1 was born at 34 weeks with multiple birth defects. At age 3 she had marked short stature, microcephaly, triangular face, and VACTERL features (cervical vertebral anomaly, VSD, patent foramen ovale, horseshoe kidney, and dangling thumb). Haploplex sequencing revealed one novel mutation in FANCI (p.Cys1014Tyr) and one previously reported mutation (p.Tyr487X).NCI 309-1 was one of fraternal twins conceived by in vitro fertilization and delivered at 32 weeks by C-section. At age 8 she had microcephaly, a small, triangular face, small eyes, Chiari malformation, and a small pituitary gland with poorly visualized pituitary stalk. Her VACTERL features included small neck, narrow C5 vertebra, bilaterally hypoplastic thumbs, absent radial pulses, and bilateral ureteric reimplantation for reflux. Her FANCI WES identified two mutations, p.Ser347Pro and p.Gly401Glufs*3.Conclusion: These three cases with FANCI, plus four among 13 with FANCI in the literature constitute seven of 16 cases with FANCI with VACTERL features (44%), significantly higher than the predicted 5%. Recent studies demonstrated that VACTERL features were more frequent than the expected 5% in individuals with FANCB, D1, D2, J, N, and O (Alter and Rosenberg, Mol Syndromol 2013) and L (Vetro et al, Hum Mut 2015). Mutations in FANCI should be added to the genotypes with a very high frequency of the VACTERL phenotype. DisclosuresNo relevant conflicts of interest to declare.

PP.27.24

Objective: Takayasu arteritis (TA) is a rare chronic vasculitis of the aorta and its branches. Infections, autoimmunity and genetic factors, as suggested by family clustering, may play a role in its pathogenesis. In this report, we describe familial TA in twin Tunisian sisters. Design and method: TA was diagnosed according the classification of the criteria of the American College of Rheumatology 1990. Results: Case1: A female patient (twin A) born to non-consanguineous parents, with no remarkable family history, had been diagnosed in our department with TA at the age of 16, after presenting with syncopal attacks, absent radial pulse, 4-limb blood pressure inequality and persistently raised inflammatory markers. Catheter and computed tomography (CT) angiography revealed stenotic abnormalities of both subclavian arteries. She was started on corticosteroids and had a carotid-humeral bypass. Over the next several months, she developed more stenosis of the central retinal, the left subclavian, the right humeral arteries, the aortic arch, and the carotid-humeral bypass. The management included corticosteroids, cyclophosphamide and surgical treatment. In 2001, she was readmitted with a setting of sudden right hemiplegia and aphasia. On investigation, she had an ischemic stroke by occlusion of the left middle cerebral artery. She received aspirin and corticosteroids. Until now, lesions remain stable. Case 2: A 32-year-old female patient (twin B), previously asymptomatic, presented to our department on November 2014 with complaints of claudication of the upper extremities, pulselessness in both brachial arteries, recurrent gastrointestinal complaints of abdominal pain, diarrhea and weight loss. She was found to have elevated blood inflammatory markers. Funduscopie examination showed pale optic disks and narrowing of retinal arteries. CT angiography exhibited stenosis of both common carotid arteries, and a superior mesenteric artery occlusion with recovery by the collateral arteries. There were no others specific manifestations of the TA. The patient received corticosteroids with a favorable evolution. Conclusions: Although rare, familial TA is an important clinical entity. To prevent delayed diagnosis and serious sequelae, a screening using pulse check and non-invasive imaging should be considered in family members of the affected patients.

Management of Grossly Displaced Paediatric Supracondylar Humeral Fractures with Delayed Presentation by Closed Reduction and Percutaneous Pinning

Background: Management guidelines are not yet clear for these patients who present late with displaced supracondylar fracture. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 24 hours or more after injury. Patients and Methods: This prospective study was conducted at the Orthopaedic and Trauma Department of Dr Pinnamaneni Siddartha Institute of Medical Sciences and Research Foundation, Chinnoutpalli from January 2010 to July 2011. A total of 44 children were included in this study who had displaced supracondylar fracture of humerus presenting late ie, after 24 hours after injury and within a week. They were treated with closed reduction of the fracture and percutaneous pinning. Method Article Kiran et al.; BJMMR, 5(2): 254-269, 2015; Article no. BJMMR.2015.026 255 Follow-up was done up to 12 months. Results: Patients were assessed on the basis of Flynn’s criteria, there were 37 excellent, 6 good results and fair results in 1 case. There were 25 boys and 19 girls. The average age of the patients was 7.5 years (range: 4 to 12 years). Fall on the outstretched hand was the mechanism of injury in 36 patients, and the other 8 patients were pedestrians struck by a motor vehicle. Non-dominant extremity was more commonly involved (30 patients). In 24 patients the fracture was displaced posteromedially (54.54%), in 18 patients posterolaterally (40.90%), and 2 patients had isolated posterior displacement (2.54%). The average delay in presentation was 57.56 hours (range: 1 day to 6 days). The mean time to surgery after presentation was 9.83 hours (range: 4 hours to 13 hours) and the mean time to surgery after trauma was 67.39 hours. Sixteen patients had one or more attempts of reduction by massaging by a quack and in 2 patients it was attempted by a qualified surgeon before they presented to us. 26 patients (59.09) visited a quack prior to presentation to us. There was a direct relation between duration of delayed presentation and the times of manoeuvre. Sixteen patients (36.36%) had neurologic complications at presentation to the emergency room of which three had median nerve palsy (6.81%) where as seven (15.90%) had isolated anterior interosseous nerve palsy and six (13.6%) had radial nerve palsy all patients showed total neurological recovery at 12 weeks follow-up. Six patients (13.63%) had vascular compromise at initial presentation of which five patients had feeble radial pulse and one had absent radial pulse, but capillary filling was adequate in all. The pulse was restored within 24 hours in all patients following reduction. Conclusion: Our preliminary results support our recommendation ie, closed reduction and percutaneous pin fixation as an effective treatment option for grossly displaced supracondylar fractures presenting late but requires good and careful judgment and also technique by the surgeon to avoid complications. Our results also support the chances of spontaneous recovery of peripheral nerve palsy and brachial artery spasm post reduction over a period of time in majority of cases though they present late.

A rare case of traumatic brachial artery injury

A relatively large proportion of peripheral arterial injuries are constituted by traumatic brachial artery injuries. Injuries to the arteries of the upper extremity and have the potential to significantly impact the outcome of the trauma patient. We report a case of 26 yr. old male patient with two glass-cut wounds in his right upper extremity, one in the arm and another in forearm. The patient presented with history of pain, brisk bleeding, pale and cold right upper extremity. It was associated with absent radial and ulnar pulses and profound neurological deficits. The brachial artery was diagnosed and confirmed by angiography and was repaired with reverse right saphenous vein graft in interpositioning. Prompt management of the traumatic brachial artery injuries is mandatory to maximize the survival of the patient and to prevent complications like compartment syndrome.

Why transradial instead of transfemoral approach for the percutaneous coronary intervention

Despite the fact that transradial approach (TRA) requires a longer learning curve than transfemoral approach (TFA), the transradial challenges are usually overcome with experience. Nowadays, in view of its benefits, there is no longer any justification for ignoring the transradial approach [1]. Multiple randomized clinical trials and reports consistently demonstrate benefits to the patient and improved outcomes from TRA [2]. TRA is particularly appealing in patients with coagulopathy, elevated international normalized ratio due to warfarin, or morbid obesity [3]. A recent metaanalysys of nine studies involving 2,977 patients with ST elevation myocardial infarction (STEMI) demonstrated an impressive nearly 50% reduction in mortality for the TR approach [4]. TR percutaneous coronary intervention (PCI) can be performed by low-tointermediate volume operators with standard equipment with a low failure rate [5]. Age over 75 years, prior coronary artery bypass graft surgery, and short stature are independent predictors of TR-PCI failure [6]. Appropriate patient selection and careful risk assessment are needed to maximize benefits offered by TR-PCI. In the Sestre milosrdnice University Hospital Centre, Zagreb, Croatia, seven interventional cardiologists perform almost 900 coronary percutaneous coronary interventions a year (40% pPCI). Our Cath Lab is one of the largest highvolume interventional cardiology centers in Croatia. In the last few years, our center has become dedicated to the radial approach with nearly 90% of PCI performed with either left or right radial access route. In time radial approach has become the first choice even in patients with STEMI. At the 2nd Advanced International Masterclass, September 2013 in New York we have had the opportunity to present our results dedicated to TR approach. In patients with STEMI undergoing primary PCI in our, radial dedicated center, there is no difference in effectiveness, safety, and blood loss between radial and femoral approach. Also there is no significant difference in either left or right radial access type [7]. There are situations when radial arterial approach is not possible (e.g. congenital anomalies, tortuous configurations, radioulnar loop, weak or absent radial pulse secondary to previous puncture or catheterization). In such situations, a common second-line approach is used (femoral or ulnar). Many clinicians considered transbrachial (TB) angiography as a high-risk and obsolete procedure. However, our overall success rate was 95.5% (21/22). There were no major complications and we noticed only two minor complications (9%), both hematomas.

Transbrachial approach — taken from the history

E mail: matias.trbusic@gmail.com Purpose: Radial arterial approach has become the default option for coronary procedures in our cath lab (>90%). However, there are situations when radial arterial approach is not possible (e.g. congenital anomalies, tortuous configurations, radioulnar loop, weak or absent radial pulse secondary to the previous puncture or catheterization). In such situations, a common second-line approach is used (femoral or ulnar). Many clinicians considered transbrachial (TB) angiography as a high-risk and an obsolete procedure. In literature, the complication rate was unacceptably high (up to 36%). The aim of this retrospective investigation was to evaluate the safety and efficiency of TB approach as an alternative to radial approach, especially after the unsuccessful radial artery puncture. Method: During the period of two years, TB coronary angiography in the antecubital region was performed in 25 patients with stable and unstable angina or valvular heart disease. In 12 patients, diagnostic procedure was followed by a coronary intervention. Reasons for TB approach were weak or absent radial pulse (12 cases) or unsuccessful radial artery puncture (13 cases). Procedures were performed by three experienced transradial invasive cardiologists (transradial success more than 95%). The catheter size was 6 Fr in all patients. Anticoagulation protocol was used while following the guidelines (aspirin, clopidogrel, unfractionated heparin) but without glycoprotein IIb/IIIa receptor inhibitors. Major complications were defined as vascular complications requiring blood transfusion or surgery or permanent neurological deficit in the lower limb. Minor complications were defined as vascular complications not requiring blood transfusion or surgery and transient neurological deficit in the lower limb. A standard post-procedural protocol was the removal of the artery sheath 3 hours after the diagnostic procedure, 6 hours after PCI and manual puncture site compression for 10 minutes. Results: Overall success rate was 96% (24/25). There were no major complications and we noticed only two minor complications (8%), both hematomas. Conclusion: TB approach, when used by dedicated transradialists, seems to be easily feasible, safe, and effective. Local vascular complications could be avoided by the cautious and sensitive puncture technique. Other important factors include the use of 6 Fr catheters, defensive anticoagulation and careful observation by the nursing team after the sheath withdrawal. TB approach has all advantages of the arm approach over the femoral (early ambulation, patient preference, suitable for patients with severe occlusive aortoiliac disease and for patients with difficulty when lying down).

Evaluation and management of pulseless pink/pale hand syndrome coexisting with supracondylar fractures of the humerus in children.

Elbow region fractures are the most common injuries in children. Among them, supracondylar fractures of the humerus are the most frequent. Massive displacement of the fractured bone causes severe injury to the soft tissue of that particular region. As a result, various types of injuries to the brachial artery such as entrapment, laceration, spasm of the vessel, and the presence of an intimal tear or thrombus formation are usually observed. The main goal of this study was to present our approach to children with supracondylar humerus fractures associated with brachial artery injuries. We would especially like to emphasize the necessity for other conservative or operative treatment concerning pulseless hand symptoms coexisting with supracondylar fractures of the humeral bone in children population. Data from 67 children were evaluated in our study. Supracondylar fractures were classified according to the Gartland’s scale. All patients had displaced extension type III injuries. During our follow-up study, we used Flynn’s grading system to evaluate functions of the elbow joint, forearm and wrist. Mean follow-up was 18 months; range, 13 months to 4 years. In the follow-up study, very good or good results were achieved in all 32 patients treated conservatively together with 6 patients with pulseless pink hand symptom. Very good or good results were achieved in 88 % of 35 patients operated on. Children who, after satisfactory closed reduction, have a well-perfused hand but absent radial pulse do not necessarily require routine exploration of the brachial artery. Conservative treatment should be applied unless additional signs of vascular compromise appear. Thus, exploration of the cubital fossa should be performed only if circulation is not restored by closed reduction.

Prevention of vascular access hand ischemia using the axillary artery as inflow

Avoiding dialysis access-associated ischemic steal syndrome (DASS) in patients with upper extremity peripheral vascular occlusive disease while creating a functional hemodialysis vascular access may be challenging. We constructed an autogenous access with primary proximalization of the arterial inflow to prevent hand ischemia in patients at high risk for this complication. Patients requiring hemodialysis access with physical findings suggesting a high risk of access-related hand ischemia (absent radial, ulnar, and brachial palpable pulses associated with small calcified vessels by ultrasound examination) underwent a primary arteriovenous fistula transposition procedure utilizing the axillary artery for inflow. The arteriovenous fistula was either a reversed flow basilic vein transposition supplemented by valvulotomy (n = 22); a translocated reversed basilic vein (n = 4); a cephalic vein harvested into the forearm and placed in a loop configuration for axillary artery inflow (n = 3); or a translocated reversed saphenous vein (n = 1). Thirty patients with a mean age of 60 years (range, 31-83 years) underwent successful primary axillary artery inflow procedures during a 3-year period. Of these, 23 (77%) were female and 25 (83%) were diabetic. Twenty-one (70%) had previous vascular access procedures and 10 (33%) were obese. No patient developed postoperative ischemia. Three individuals died 2, 14, and 19 months following surgery, none related to vascular access. Three accesses failed after 1, 5, and 7 months and could not be salvaged. Life-table primary, primary assisted, and cumulative patency rates were 57%, 78%, and 87% respectively at 1 year with a mean follow-up of 7 months (range, 1-25 months). Cephalic vein outflow was associated with fewer access failures, fewer interventions postoperatively, and lower rates of arm swelling (P < .01). Creating a basilic vein transposition for vascular access utilizing axillary artery inflow is a good option for patients with severe peripheral vascular disease. It offers a high patency rate and the prevention of DASS. Retrograde basilic vein outflow through the median cubital and cephalic vein is associated with the best outcome and is the recommended configuration.

The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

English

Takayasu arteritis is a rare granulomatous systemic disease characterized by stenosis or obliteration of large & medium sized arteries mainly aorta and its main branches as well as pulmonary artery. Although this disease has variable presentation, but its presentation as Dilated cardiomyopathy is rare. Renal involvement is also less frequently reported in young males. We report a case of 20 yr old male who presented with features of congestive heart failure, renal failure and incidentally detected with absent right radial pulse and hypertension .His CT angiography revealed occlusion of right subclavian artery, superior mesenteric artery & bilateral renal arteries with splenic infarct suggestive of Takayasu arteritis. This case report illustrates a rare case of dilated cardiomyopathy and renovascular hypertension with renal failure secondary to Takayasu Arteritis which responded with systemic corticosteroids.

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

BackgroundThe management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus.MethodsA retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair.ResultsIn this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise.ConclusionsThe presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Isolated Axillary Artery Injury due to Blunt Trauma in Ice Hockey

We report the first case of a purely isolated axillary artery dissection because of focal blunt trauma to the axilla. A 42-year-old man presented to our outpatient orthopedic clinic 7 days after a fall during a hockey game whereby another player's skate blade struck the patient directly in the axilla without disrupting the skin. The patient denied having any symptoms of shoulder dislocation but experienced some pain and numbness, which subsided rapidly. Then he developed a cool hand with exertional claudication. Physical examination revealed absent radial and brachial pulses. Computed tomographic angiography demonstrated dissection of the distal axillary artery extending to the middle two-thirds of the brachial artery. Following urgent consultation with vascular surgery, the patient was treated operatively with reverse saphenous interpositional grafting and embolectomy. This case illustrates the need to have a heightened index of suspicion to all injuries to the axilla and the importance of performing careful soft tissue and neurovascular examinations in hockey players presenting with shoulder complaints, even when bony injury is not present.

Teaching Video Neuro Images : Asymptomatic subclavian-carotid double steal phenomenon due to innominate artery stenosis

A 67-year-old asymptomatic man was referred after detection of absent right radial pulse and asymmetry in systolic and diastolic pressures between his arms. Duplex ultrasonography showed a “to and fro” waveform pattern in the right internal carotid artery and a reversal of flow in the right vertebral artery (videos 1 and 2 on the Neurology ® Web site …

Buerger’s disease

A 58-year-old man of eastern European descent with a 12-year history of Buerger’s disease presented with painful acral gangrene of fingers II to V of the left hand and fingers II to IV of the right hand (Panel A). He reported the unprotected use of a commercially available cold pack on both hands after an insignificant blunt trauma as a possible trigger of the lesions. The patient used to be a heavy smoker, but reported to have stopped smoking cigarettes 2 years ago. However, regular consumption of cannabis owing to a chronic pain condition was admitted, and at least sporadic nicotine exposure was suspected clinically. The initial non-invasive vascular work-up demonstrated absent ulnar and weak radial artery pulses bilaterally. The pulse volume recordings of all fingers were severely dampened despite normal tracings at the level of the upper arm and forearm in both extremities. The results indicated distal occlusive disease of the forearm and finger arteries bilaterally, and therefore we decided to refrain from performing additional angiographic imaging due to a lack of interventional therapeutic options. Despite proper local surgical care, intravenous vasodilator therapy with the prostacyclin analogue iloprost, and surgical thoracic sympathectomy, the lesions deteriorated. After a total treatment period of 22 months, healing was finally achieved by adding the phosphodiesterase inhibitor sildenafil to the patient’s therapy in an off-label use as a vasodilator. Thereafter, sildenafil could be tapered off over the course of several weeks without relapse (Panel B). Buerger’s disease is a non-atherosclerotic segmental inflammatory disease that most commonly affects small and medium-sized arteries and veins. The pathogenesis of this disease condition is still largely unknown, but exposure to Images in vascular medicine

A 12-year-old girl with absent radial pulse: arterial thoracic outlet syndrome with subclavian artery aneurysm and thrombosis of the brachial artery

Brachial arterial occlusion is rare in children and adolescents. Once a traumatic cause is excluded, the differential diagnosis consists of a variety of rare conditions. We report the case of a 12-year-old girl whose presenting symptoms--an absent radial pulse and Raynaud's phenomenon of the right hand--could be easily mistaken for a vasculitis. She was found to have arterial thoracic outlet syndrome with right subclavian artery compression and aneurysm formation caused by an anomalous first rib and consecutive thromboembolic occlusion of the brachial artery. The diagnosis and differential diagnosis of this condition are reviewed.

Coronary Subclavian Steal Syndrome Unamenable to Angioplasty Successfully Managed with Subclavian-Subclavian Bypass

Purpose. Coronary-subclavian steal syndrome (CSSS) is defined as a reversal of flow in a previously constructed internal mammary artery (IMA) coronary conduit, producing myocardial ischemia. We present a case of CSSS which could not be ameliorated with endovascular therapy and necessitated a subclavian-subclavian bypass. Case Report. 80-year-old Caucasian male with history of CABG presented with syncope. He had absent left-sided radial pulse with blood pressure being 60/40 on left arm and 130/80 on the right. He underwent cardiac catheterization for NSTEMI which showed patent left internal mammary artery graft to left anterior descending coronary artery with retrograde flow, and diagnosis of coronary subclavian steal syndrome was made. Complete occlusion of proximal left subclavian artery was identified. Percutaneous angioplasty failed because of calcified plaque causing 100% occlusion. Carotid doppler showed bilateral carotid artery disease. He finally underwent subclavian-subclavian bypass which resolved his condition. Conclusion. Subclavian-subclavian bypass is a successful alternative to carotid-subclavian bypass for management of CSSS especially with concomitant critical carotid artery atherosclerotic disease.