Presentation
History of left upper limb pain and restricted movements. There was no history suggestive of trauma. Patient had a facial rash since few days.
Patient Data
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This attempted selective left upper limb angiography images reveal that the catheter colud not be hooked into the subclavian artery. The shot was taken while keeping the catheter in arch of aorta.
There was significant narrowing of proximal aspect of left subclavian artery, while its mid and distal parts (especially the superior and anterior aspects) are completey thrombosed. The vertebral artery is not opacified and rich collaterals are seen beyond proximal aspect of left subclavian artery. The internal mammary artery is opacified.
Partial thrombosis of origin of left common carotid artery is also seen.
Case Discussion
Color doppler also revealed partial thrombosis of left subclavian artery and complete lack of flow in left axillary, left brachial, left radial and left ulnar artery. Normal flow was seen in left common carotid artery.
In this setting of massive left upper limb arterial thrombosis, the only possibility to save the limb was to perform brachial artery endarterectomy and thrombectomy.
On distal brachial artery endarterectomy and proximal thrombectomy with fogarty catheter, large amount of white thick thrombus was removed from the brachial artery. Significant forward blood flow was established and the artery closed. Patient was put on heparin and antiplatelets.
Next day, the patient developed left posterior circulation infarct. The possibility of an embolus getting logged in left vertebral artery was considered, either during angiography or embolectomy.
Eventually, over the period of one week, the patient developed gangrene of left distal upper limb and eventually had to undergo left upper limb shoulder disarticulation.
It was considered that likely due to some auto immune disease or increased tendency to thrombosis, there was rapid and accelerated re-thrombosis of left upper limb vessels. The possibility of Takayasu's arteritis was considered.
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