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PATIENT STORY

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A 53-year-old woman presented with severe right upper extremity rest pain. She reported a history of bilateral Raynaud phenomenon with cold exposure for many years. She also had progressively worsening right second- and third-digit pallor and pain on arm elevation for 1 year. Physical examination revealed a pale right hand (Figure 14-1A and B) with tender digits, absent radial and ulnar pulses, weakly palpable brachial pulse, and associated hand-grip weakness. No abnormalities were noted on her left upper extremity vascular or neurologic examination.

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FIGURE 14-1

Severe pallor noted on arm elevation (A) with dependent rubor on dependency (B) in the right arm.

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She had undergone thromboembolectomy and patch angioplasty of the right brachial artery with a normal upper extremity arteriogram 4 months prior for treatment of brachial artery occlusion. She had a negative rheumatology and thrombophilia evaluation at that time, and after initial improvement her symptoms recurred a month later. She underwent a brachioradial bypass, again with temporary resolution of her symptoms.

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The patient sought a second opinion and noninvasive vascular studies revealed the absence of right digital laser Doppler signals at baseline and after warming (Figure 14-2). Upper extremity computed tomographic arteriogram (CTA) (Figure 14-3) revealed occlusion of subclavian artery with abduction. Upper extremity arteriogram confirmed occlusion of the mid brachial artery with multiple emboli noted in circumflex humeral and collateral arteries (Figure 14-4A and B; Figure 14-5A and B). The distal radial artery was reconstituted via collaterals through the interosseous artery to provide flow into the palmar arch (Figure 14-5B).

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FIGURE 14-2

Upper extremity noninvasive laser Doppler arterial studies reveal undetectable Doppler signals in the right digits both at rest and postwarming.

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FIGURE 14-3

Computed tomographic arteriogram (CTA) shows right subclavian artery occlusion with arm in abducted position.

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FIGURE 14-4

Digital subtraction arteriogram showing a patent right subclavian artery with an area of filing defect or lucency (arrow) at level of clavicle and first rib intersection (A). Multiple small filling defects suggestive of thrombus or embolus (arrows) noted in the circumflex and collateral branches (B).

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FIGURE 14-5

Arteriogram of right upper extremity shows occlusion of brachial artery (arrow) with multiple small collaterals (A) and reconstitution of the interosseous artery (arrow) via collateral branches (B).

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