Swelling Of Upper Extremity Research Articles

A Rare Case of Metastatic Colon Cancer Involving the Right Atrium Presenting as Superior Vena Cava Syndrome

Colorectal cancer is one of the most common forms of malignancies and is well documented to metastasize to liver, lungs and peritoneum. Only a handful of well-documented cases of colorectal cancer metastasis to the right atrium have been documented. As such, we report a rare case of colon adenocarcinoma that metastasized to the right atrium and resulted in superior vena cava (SVC) syndrome. The patient is a 50-year-old male with history of hyperlipidemia, anxiety and metastatic colon cancer involving lungs and liver previously treated with chemotherapy and recently with immunotherapy who was transferred to our hospital for management of occluded SVC with the mass extending into the left atrium. The patient initially presented at another hospital for facial and upper extremity swelling and shortness of breath. A CT of the chest noted occluded SVC with a right atrial mass. This was further confirmed on transesophageal echocardiography which noted a large mass occupying most of the right atrial cavity measuring 6.8cm x 4.6cm and was noted to prolapse across the tricuspid valve in to the right ventricle. He was started on Eliquis and was transferred to our hospital for further management. He underwent an angiovac thrombectomy with Interventional Radiology (IR). During the procedure, findings of right atrial mass extending into the SVC were noted with subsequent partial debulking of the mass. Post procedure, the patient reported moderated improvement of his symptoms of dyspnea and swelling. Microscopic pathologic examination of the excised mass exhibited histomorphological features of metastatic colorectal cancer as cells demonstrated strong and diffuse nuclear reactivity for CDX2 stain. CT surgery evaluated patient for further surgical evaluation of right atrial mass, however he was deemed a poor surgical candidate. As such, IR placed a stent in the SVC to further alleviate SVC occlusion. Prior to discharge, Oncology also evaluated patient and recommend continued palliative radiation as outpatient. Conclusion: Although rare, any patient with a history of colorectal adenocarcinoma who presents with cardiopulmonary symptoms and suspicious cardiac mass should undergo evaluation for possible cardiac metastasis. It is recommended that a multidisciplinary approach involving cardiologists, oncologists, IR, and cardiothoracic surgeons is essential for determining the optimal therapeutic regimen for such patients.1483_A Figure 1. CT of the chest exhibiting the Right atrial mass1483_B Figure 2. Right atrial mass and thrombus extending into superior vena cava1483_C Figure 3. Microscopic pathologic examination of the excised mass exhibited histomorphological features of metastatic colorectal cancer as cells demonstrated strong and diffuse nuclear reactivity for CDX2 stain

Abstract No. 677 Outback re-entry device for the treatment of central venous occlusion in hemodialysis patients

To report our institutional experience with the Outback re-entry device for the treatment of central venous occlusion in hemodialysis patients. Since January 2013, 8 consecutive patients (4 males and 4 females, mean age: 63.2 years) receiving hemodialysis underwent endovascular treatment for central venous occlusion using the Outback re-entry device after failed attempts of guidewire traversal. The patients had been referred for percutaneous angioplasty due to increased venous pressure during hemodialysis in 4 patients and upper extremity swelling in 4 patients. The mean age of their fistulas since creation was 21.3 months. Six patients had previously received endovascular treatment for malfunctioning fistulas. Occlusion sites were in the subclavian vein (n=4) and brachiocephalic vein (n=4). In all patients, the guidewire was passed into the subintimal plane but could not be re-directed into the distal true lumen. The Outback re-entry device was used as a bail-out measure with technical success in all cases. All patients underwent balloon angioplasty; 6 of them had provisional bare metallic stent placement due to elastic recoil. The fistulas were functionally restored and arm swelling was relieved in all cases. Excluding three patients who were lost to follow-up, the fistulas were functional up to a mean period of 8.3 months. During this time, 4 patients underwent repeated intervention. There were no complications related to the procedure. The Outback re-entry device is a feasible and safe bail-out option in patients who fail conventional techniques for wire traversal during endovascular treatment of central venous occlusion.

Thymoma Inducing Superior Vena Caval Syndrome

Thymomas are one of the most common tumors of the anterior mediastinum afflicting adult population. Approximately half of the patients have no complaints, and the diagnosis is, made incidentally on the chest radiograph done for different issues. However, symptoms may arise from compression of the mass on the trachea, the recurrent laryngeal nerve, the esophagus, the superior vena cava or other mediastnal structures. Invasive thymoma with transcaval extension to the right atrium is a rare cause of superior vena cava syndrome. We present a case of a 63-year-old man presenting with dyspnea on exertion and facial and upper extremity swelling. Physical examination showed marked edema of face, upper torso and distention of superficial veins of the anterior chest wall and jugular veins. On elaborate investigations, it was revealed to be a case of Type B1 Masoka IVA invasive thymoma. The mass was removed employing open-heart surgery along with SVC reconstruction.

The Appropriate Use of PICC Lines in Inflammatory Bowel Disease

Our patient is a 49-year-old male with a history of Ulcerative Colitis (UC) with recurrent flares on Remicade and Prednisone who presented with acute-onset left upper extremity swelling. One day prior to his admission, he was discharged from an outside hospital after being treated for a UC flare for 9 days. During this hospitalization, a peripherally inserted central catheter (PICC) line was placed for poor vascular access and repeated blood draws. His left arm PICC line was removed on the day of discharge without complication. However, the following morning he developed progressively worsening swelling and skin discoloration of his left arm. On presentation, his vitals were stable. Examination of his left upper extremity revealed non-pitting edema in the entirety of his left arm with erythematous skin overlying his biceps and antecubital fossa with ecchymosis. His vascular and neurological exams were intact. Duplex of the left arm revealed a DVT from the left subclavian vein to the axillary vein and involving the basilic and medial brachial veins as well as the cephalic vein in the upper arm. He was promptly started on intravenous heparin. He greatly improved and was discharged on anticoagulation which he will continue for at least 3 months. The insertion of PICC lines has become commonplace in medical practice due to a myriad of reasons such as reliable venous access, ease of insertion, and cost-effectiveness. Despite these benefits, insertion of these central venous catheters (CVCs) is not without risk. Such risks include central lineassociated bloodstream infections and venous thromboembolism. A concern was raised regarding the suitable use of a PICC line in our patient with a chronic inflammatory disease for the purpose of vascular access. The literature reveals that many PICC lines are not actively used or were inserted in patients who also had peripheral intravenous catheters. A recent study showed that 1 in 5 inpatient providers did not know that their patients had CVCs, with lack of awareness being greatest for PICC lines. Guidelines on the proper use of PICCs have been proposed with insertion rated as appropriate when the proposed duration of use for frequent phlebotomy or difficult venous access was 6 or more days. Although there are several advantages of PICCs, the duration of venous access, type of infusate, and specific reason for use should be carefully evaluated prior to placement to minimize the risk to our patients.

Combined endovascular and surgical (hybrid) repair of type B aortic dissection with aneurysmal degeneration involving Kommerell's diverticulum and aberrant right subclavian artery

A 44-year-old woman presented with a 3-year history of type B aortic dissection. A computerized tomographic scan revealed a type B aortic dissection with a 4.1-cm proximal descending thoracic aneurysm involving a Kommerell’s diverticulum with an aberrant right subclavian artery. Eleven months later, the aneurysm had enlarged to 6 cm (Cover, posterior view; A, anterior view). The patient had intermittent chest pain, dysphagia, and left upper-extremity swelling secondary to innominate vein compression. A two-stage hybrid approach was recommended. The first stage consisted of a right carotid subclavian bypass with endovascular occlusion of the aberrant right subclavian artery and a left carotid subclavian bypass. Two months later, the repair was completed with a proximal ascending aorta-to-right common carotid and left common carotid bypass through a median sternotomy (B) and endovascular repair of the distal aortic arch and proximal thoracic aneurysm with an endovascular graft originating in the distal ascending aorta. Two years later, the patient is asymptomatic with good blood pressure control and normal kidney function, and the left arm swelling has resolved. On follow-up computerized tomographic scan, the proximal descending aneurysm has decreased to 5.2 cm, with no endoleak, and stable distal aortic dissection (C). Aberrant right subclavian artery is the most common aortic arch anomaly. Endovascular and hybrid repairs of aneurysmal degeneration of Kommerell’s diverticulum, the anomalous artery, and/or the aorta have been reported. When aneurysmal degeneration of the anomalous right subclavian artery occurs, a concomitant abdominal aortic aneurysm is present in 25% of cases. Type B aortic dissection in the presence of an anomalous right subclavian artery with Kommerell’s diverticulum is rare. A single case has been reported using extra-anatomic bypasses for the subclavian arteries and an endovascular graft distal to the left common carotid. The case herein reported is the first report of complete arch debranching for hybrid repair of a type B aortic dissection with aneurysmal degeneration in the presence of an anomalous right subclavian artery with a Kommerell’s diverticulum.

Bilateral Upper Extremity Edema in the Psoriatic Arthritis Case

Psoriatic arthritis (PsA) is a seronegative spondyloarthropathy characterized by peripheral arthritis, enthesis, spondylitis, and psoriasis. Lymphedema arises from the slowing of lymphatic flow because of inflammatory or noninflammatory diseases such as tumors, infections, bursitis, rheumatoid arthritis, and polymyalgia rheumatica. It is commonly encountered in one or more regions of distal extremities. Lymphedema is a rare complication of PsA, and it is commonly seen asymmetrically and in lower extremities. We aimed to report a case, who followed-up with diagnosis with PsA and with complaints of upper extremity swelling and bilateral upper extremity lymphedema diagnosed as a result of the review.

Upper Extremity Deep Venous Thrombosis

The patient was a 34-year-old man currently serving in the military who was referred to a physical therapist by his primary care physician for a chief complaint of worsening right shoulder pain and paresthesias of the first, second, and third digits of his right hand, as well as right upper extremity swelling. Doppler ultrasonography was performed, and the presence of an occlusive thrombus in the right distal subclavian and axillary veins was revealed.

Rescue Vascular Access in the Emergency Department

Rescue Vascular Access in the Emergency Department

Chronic Lymphedema Due to Constriction

We describe an unusual presentation of lymphedema due to constriction of the left upper extremity in a 71-year-old woman. The patient reported an onset of left upper extremity swelling 6 months prior to presentation, after she slept wearing a magnetic health bracelet. However, she was not accurately diagnosed until she visited our department. The diagnostic workup included a history and laboratory and radiologic findings, which were all normal except for the swollen upper extremity and findings on lymphoscintigraphy. She was diagnosed as suffering from chronic lymphedema due to constriction that only affected her left arm. She underwent complete decongestive therapy and achieved mild improvement of her swelling.

VASCULAR ACCESS GRAFT AND NATIVE ARTERIAL BRANCH FISTULOUS FORMATION

This is the first reported case of an unusual complication of upper extremity swelling of the arm in a patient with an arteriovenous (AV) graft for haemodialysis. A graftogram demonstrated an aberrant fistula formation between the native arterial branch and the AV graft (aberrant arterio-graft fistula). Inadvertent back wall laceration of the AV graft during haemodialysis cannulation was postulated to be the aetiology. Aberrant arterio-graft fistula formation may be hard to diagnose because of the presence of thrill or bruit at the level of the anastomoses and rarity of the complication. Progression of extremity swelling with or without central venous occlusion should raise the suspicion and sought further investigation. Proper cannulation techniques prior to haemodialysis may prevent such complications.

Index of Suspicion

A 17-year-old girl presents with intermittent right upper extremity swelling and pain over the past 2 years. Her symptoms began after an episode of Bell’s palsy. She describes swelling and an “electrical shooting” pain in the right shoulder that radiates toward her hand, followed by a cool feeling of the hand and decreased range of motion of the arm. The episodes occur during both summer and winter and can last anywhere from 2 to 30 days. Initially, between these episodes, she regained normal function, but recently has noted residual weakness. She denies any history of trauma, fever, rash, or muscle weakness. On examination, there is swelling of the entire right arm. The nails are normal. The right arm is colder in comparison with the left and has decreased hair growth. Peripheral pulses and capillary refill were normal. Pinprick and temperature sensations are intact, without hyperesthesia. Range of motion of the right arm, forearm, and hand is compromised because of pain. Except for her right arm, she is warm, well perfused, and free of joint swelling. The muscle tone is normal, and strength in the other muscle groups is 5/5. Laboratory studies reveal an erythrocyte sedimentation rate of 15 mm/h, C-reactive protein <0.5 mg/dL, white blood cell count of 6.3 to 103/μL, and creatine phosphokinase level of 100 U/L. The results of additional laboratory studies, including antinuclear antibody, rheumatoid factor, antibody test for Borrelia burgdorferi , rapid plasma regain test for syphilis, urine-amplified DNA assay for Chlamydia and gonorrhea, hemoglobin electrophoresis, serum lactic acid dehydrogenase level, and uric acid level, are normal or negative. Radiographs of cervical spine, chest, right elbow, forearm, and hand as well as magnetic resonance imaging (MRI) of the brain, cervical spine, and entire arm are normal. Right upper extremity vascular duplex ultrasonography shows normal …

Abstract P2-11-13: The Effect of Positive Axillary Lymph Nodes on Symptoms, Physical Impairments, and Function

Abstract Purpose/Objective(s): The role of axillary lymph node (ALN) sampling in breast cancer (BC) treatment continues to evolve, and BC patients are recommended for post-operative regional nodal radiation therapy (RNRT) based on the number of positive ALN. RNRT is recommended for patients with 4 or more positive ALN, but it remains controversial in patients with 1–3 positive ALN and is rarely recommended for patients without positive ALN. Consideration of anticipated functional impairments often guides decision making. The purpose of this analysis is to investigate functional impairments in BC patients with varying numbers of positive ALN. Materials/Methods: 166 women were diagnosed with BC between 2001–05 and enrolled and treated in a prospective surveillance physical therapy program. 110 had zero positive ALN, 37 had 1–3 positive ALN, and 19 had 4 or more positive ALN on either sentinel LN biopsy or ALN dissection. Participants' upper extremity (UE) range of motion, strength, and limb volume were assessed pre-operatively and at 1, 3, 6, 9, and 12+ months post-operatively by a physical therapist. Limb volume was assessed using infrared optoelectronic perometry. At 12+ months, overall health status, UE symptoms and function, and physical activity levels were reported using standardized questionnaires. Chi-square tests and one-way ANOVA analyses were used to determine significance between groups (p ≤ 0.05). Results: Of these 166 patients, 94 received mastectomy and 72 received lumpectomy, while 41 received RNRT and 58 received whole breast tangent RT. No significant differences were found between groups with regard to age or race. The number of dissected LN was not significantly different between those patients with 1–3 positive ALN and 4 or more positive ALN. Rates of lymphedema and seroma were not significantly different between those patients with zero positive ALN and 1–3 positive ALN, and rates of cording were not significantly different between any of the groups. Increased lymphedema (p = 0.03) and seroma (p = 0.005) were seen in those patients with 4 or more positive ALN compared to those patients with zero positive ALN, but this may also be related to a significantly greater number of dissected LN in the former group. By 12+ months post-operatively, there were no differences in shoulder abduction, shoulder flexion, internal rotation, or external rotation between groups. No differences were seen between groups in self-reported fatigue, UE swelling or weakness, arm stiffness, or ability to climb stairs. Conclusions: Functional impairments represent an important category of morbidity for BC survivors and should be considered in pre-treatment decision making. The number of positive ALN may not correlate with increased impairment over the first year of treatment when a prospective surveillance physical therapy program is part of the plan of care. Additional research is needed to assess longer-term changes and the impact of axillary surgery and/or radiation in the context of aggregate effects of other BC treatment modalities. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-13.

Abstract P2-11-14: Symptoms, Physical Impairments, and Function in Breast Cancer Patients with Negative Axillary Lymph Nodes

Abstract Purpose/Objective(s): Breast cancer (BC) patients are recommended for post-operative regional nodal radiation therapy (RNRT) based on the number of positive axillary lymph nodes (LN). While RNRT is recommended for patients with 4 or more positive LN, it remains controversial in patients with 1–3 positive LN. For these patients, consideration of anticipated functional impairments often guides decision making, but these considerations are confounded by the inseparable effects of disease in and treatment of the axilla. The purpose of this analysis is to investigate the effect of various therapies on functional impairments in BC patients without axillary disease. Materials/Methods: 166 women were diagnosed with BC between 2001–05 and enrolled and treated in a prospective surveillance physical therapy program. 110 had zero positive axillary LN on either sentinel LN biopsy or axillary LN dissection and were analyzed for this report. Participants' upper extremity (UE) range of motion, strength, and limb volume were assessed pre-operatively and at 1, 3, 6, 9, and 12+ months post-operatively by a physical therapist. Limb volume was assessed using infrared optoelectronic perometry. At 12+ months, overall health status, UE symptoms and function, and physical activity levels were reported using standardized questionnaires. Chi-square tests and one-way ANOVA analyses were used to determine significance between groups (p ≤ 0.05). Results: Of these 110 patients, 34 received mastectomy without RT, 21 received mastectomy with RNRT, 10 received lumpectomy alone, and 45 received lumpectomy with whole breast tangent RT. No significant differences were found between groups with regard to stage, ER/PR status, and number of dissected LN. Rates of lymphedema, cording, and seroma were not significantly different between groups. By 12+ months post-operatively, there were no differences in shoulder abduction, shoulder flexion, internal rotation, or external rotation between groups. No differences were seen between groups in self-reported fatigue, UE swelling or weakness, arm stiffness, or ability to climb stairs. Conclusions: Functional impairments represent an important category of morbidity for BC survivors and should be considered in pre-treatment decision making. In patients without axillary disease, post-operative RNRT or whole breast tangent RT may not contribute significantly to impairment over the first year of treatment when a prospective surveillance physical therapy program is part of the plan of care. Additional research is needed to assess longer-term changes and the impact of radiation in the context of the aggregate effect of disease burden combined with other BC treatment modalities. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-11-14.

Permanent Pacemaker‐Related Upper Extremity Deep Vein Thrombosis: A Series of 20 Cases

Upper extremity deep vein thrombosis (DVT) has become a common occurrence nowadays due to emergence of multiple newer risk factors, such as implantation of permanent pacemaker (PPM) and implantable cardioverter-defibrillators. We are reporting 20 cases of upper extremity DVT related to PPM implantation. All the patients presented within 6 months, with unilateral upper extremity swelling (90%), pain (45%), erythema (15%), and other less frequent features. Venography established the diagnosis in all the cases. Considering the distribution of possible risk factors of venous thrombosis among our patients, diabetes was the most frequent (present in 45%) followed by smoking (35%), hypertension (30%), obesity with body mass index ≥30 (30%), history of acute myocardial infarction (25%), chronic obstructive pulmonary disease (20%), and history of congestive cardiac failure (15%). Antiplatelets were not found protective against the development of this situation. There was no statistically significant difference in respect to venous access, number of leads, use of previous temporary pacing lead, or poor left ventricular systolic function (ejection fraction ≤40%) among the six patients who presented with complete occlusion of subclavian vein compared to the rest of the 14 patients who had partial occlusion. There were complete resolutions of symptom in 85% of patients after 6 months of anticoagulation therapy in the form of initial intravenous unfractinated heparin followed by oral warfarin. Anticoagulation with warfarin for 6 months with initial intravenous unfractionated heparin was a safe and effective mode of therapy in most of the patients with PPM related upper extremity DVT.

Grey Turner's sign

A 51-year-old Romanian male without a significant past medical history presents with shortness of breath, bilateral lower extremity swelling and right upper extremity swelling and pain. Doppler ultrasound confirmed an extensive right upper extremity Deep Vein Thrombosis (DVT). He was anticoagulated with intravenous heparin. He developed hemodynamic instability on Day 2 of hospitalization and required vasopressors. A left femoral triple lumen catheter was placed urgently. Computed tomography (CT) angiography of the chest excluded pulmonary embolism. A transthoracic echocardiogram revealed severely impaired left ventricular function with an ejection fraction of 10%. …

Incidental Findings of Tumors in a Routine Venous Duplex

Introduction Deep venous thrombosis (DVT) is a condition routinely evaluated for in a vascular laboratory on a daily basis. Patients usually present with symptoms of peripheral pain, swelling, shortness of breath, or chest pain. Pain and swelling are not symptoms unique to DVT, however, and an ultrasound test could potentially serve as a basis for incidental findings that would serve as an underlying reason for the patient's symptoms. It is important to recognize the role in evaluating flow characteristics and using appropriate methods for identifying deep veins to exclude, or include, DVT as a cause for symptoms. Case Reports Two case studies are presented here in light of excluding DVT and identifying tumors. The first patient presented to the emergency department with left upper extremity swelling and pain. A left upper-extremity venous ultrasound was performed to discover all veins were fully compressible. No intraluminal thrombus was noted, yet all veins demonstrated abnormal, continuous flow. A significant proximal venous obstruction was indicated at the level of the left clavicle by ultrasound based on the observed abnormal flow. A chest X-ray and computed tomography was ordered, and the presence of a large Pancoast tumor was discovered. It extended superiorly from the left lung towards the clavicle, extrinsically compressing the proximal left subclavian vein. The patient subsequently had concurrent chemotherapy and radiation therapy treatment and rehabilitation. The second patient presented with a mild fever and tachycardia and was status postcervical tumor surgery. The ultrasound revealed multiple segments of homogenously echogenic, Doppler-silent, incompressible structures visualized adjacent to the deep vasculature system throughout bilateral lower extremities. These structures could easily be mistaken for DVT as they appeared similar in B-mode character. Clear identification of venous flow demonstrated around these structures differentiated the veins, and the contiguous visualization of the vein lumen, from these structures. These structures were diagnosed as Schwannoma, tumors consisting only of Schwann cells, that run along the nerves, which in turn run along the deep vasculature.

Aortosternal Venous Compression: Innominate Vein Compression by the Innominate Artery

A19-year-old woman presented with left upper extremity swelling and headache for 3 months. The swelling was intermittent, and often combined with paresthesia. She had no significant medical or surgical history. A computed tomography scan of the head and neck taken 2 months previously at another department showed no abnormality of the superficial and deep neck structures. On the physical examination, mild edema in the left shoulder and arm region was noted, without compromise of brachial or radial pulsation.

Successful Treatment of Superior Vena Cava Rupture with Placement of a Covered Stent: A Report of Two Cases

Superior vena cava syndrome (SVCS) is characterized by the development of symptoms, including facial, head, neck, chest, and upper extremity swelling, shortness of breath, and headache, in the setting of superior vena cava (SVC) stenosis or occlusion [1, 2]. SCVS may be caused by a variety of benign and malignant conditions. Since the development of selfand balloon-expandable stents, endovascular repair has become the first-line therapy for the treatment of SVCS [3–5]. The most common complications of stent placement include pulmonary embolus (PE), stent migration, fracture, and misplacement [6]. There are a few case reports describing subclinical rupture after stent placement and death secondary to cardiac tamponade from balloon dilatation of the SVC [7, 8]. Additionally, there is one case report describing the placement of a covered stent for superior vena cava rupture (SVCR) in a non-peer-reviewed journal [9]. We present two cases of SVCR during SVC balloon angioplasty and bare metal stent placement that were successfully treated with placement of a covered stent. Placement of a covered stent may provide a rapid definitive treatment to prevent death from SVCR.

Carotid Artery Pseudoaneurysm

Introduction The development of a carotid artery pseudoaneurysm (PA) after carotid endarterectomy is a rare complication with a reported incidence of 0.25% to 0.74%. It results from suture line failure or disruption, degeneration of the arterial wall, or patch material and/or infection. Patients present with neck swelling and pain that can be complicated by thrombosis, rupture, or infection. Case Report We describe a 72-year-old man who underwent bilateral carotid endarterectomies in 1987. He presented with bilateral upper-extremity swelling after a kidney transplant. An upper-extremity venous duplex performed with a Philips iU22 (Bothell, WA) with an 8-4 MHZ linear transducer revealed normal phasic pulsed Doppler waveforms. Compression images of the patient's left side of the neck revealed acute thrombus within the internal jugular vein. An incidental finding of bilateral common carotid PAs at their proximal patch surgical sites was noted. The right carotid PA measured 1.8 × 2.6 cm, whereas the left measured 2 × 1.3 cm. Discussion Carotid artery PA has been reported within 2 days or as late as 22 years after surgery. A true carotid aneurysm is usually caused by atherosclerosis or arteritis, whereas a carotid artery PA develops after endarterectomy as the result of infection, suture line disruption, or degeneration of the arterial wall or at the patch angioplasty site. A potential for rupture, embolization, thrombosis, or compression of the cranial nerves requires urgent attention. The conventional treatment approach is excision and repair via a vein graft. However, the risk of complications, especially cranial nerve injury, is high. A reasonable alternative to open surgery is covered carotid artery stenting if infection is excluded as the etiology of the pseudoaneurysm. Conclusion Although the diagnosis of carotid artery PA is usually suspected clinically, an imaging procedure is necessary for confirmation. Duplex scanning is the gold standard that can be augmented by arteriography or magnetic resonance imaging.

Two Cases of Upper-Extremity Swelling

Two adolescents presented to our emergency department with isolated, acute onset upper-extremity swelling. In their initial emergency department evaluations, both patients were found to have a deep venous thrombosis. Despite their similar presentations, the etiologies of their deep venous thrombosis were very different. After further evaluation, one patient was diagnosed with Paget-Schroetter syndrome and the other with non-Hodgkin lymphoma. These cases illustrate the importance of maintaining a broad differential diagnosis and using a multidisciplinary approach to patients with the unusual and potentially life-threatening presentation of upper-extremity swelling.