Arresto de vena subclavia

Title
Subclavian artery obstruction diagnosed by CT angiogram in ER
Authors
Jose Mª Alises Moraleda. MD. Servicio de Urgencias. Hospital la Mancha Centro. SESCAM. Alcázar de San Juan. Ciudad Real. España
Carlos López Lafuente. MD. Servicio de Radiodiagnóstico. Hospital la Mancha Centro. SESCAM. Alcázar de San Juan. Ciudad Real. España
Miguel Ángel Cordero. MD. Servicio de RadiodiagnósticoHospital la Mancha Centro. SESCAM. Alcázar de San Juan. Ciudad Real. España.
Oscar Vladimir Zepeda.MD. Servicio de Urgencias .Hospital la Mancha Centro. SESCAM. Alcázar de San Juan. Ciudad Real. España
Juan Tomás López Mondejar (in memoriam).MD. Servicio de Urgencias. Hospital la Mancha Centro. SESCAM. Alcázar de San Juan. Ciudad Real. España
Acknowledgments
Conflict of interests
None
AddressJose Mª Alises Moraleda.
Calle Juan Coto nº 9. 13640.
Herencia (Ciudad Real). España
e-mail: jmalises@yahoo.es

Subclavian artery obstruction diagnosed by Chest CT angiogram in ER
The obstruction of the proximal subclavian artery creates collateral flow through the ipsilateral vertebral artery. The flow deficit created affects the brain and ipsilateral upper extremity mostly when thefunction requires to elevate the arm above the head. Nevertheless many patients are asymptomatic and the evidence of steal syndrome can only be detected by blood pressure differences in the upper extremities and diminished pulse in the affected arm.
The gold standard is angiography but the CT angiogram is a noninvasive and efficacious technique for diagnosis in the ER. The main indications forsurgical repair are the presence of neurological symptoms.
The asymptomatic patients could be managed medically. We are presenting a case report of a patient that was referred to the ER because he was found to have BP differences in the upper extremities.

Key words: subclavian artery obstruction; subclavian steal syndrome, diminished (quality) pulse, BP differences, CT angiogram.

IntroducciónThe subclavian steal syndrome is an unfrequented vascular pathology. During the last 60 years, 1617 cases have been reported in the literature, and the most publications had been between 1970 to 1990 as it is shown on graph 1.
We refer to the subclavian artery steal syndrome when there is retrograde flow into the vertebral artery associated with ipsiliateral subclavian artery stenosis or occlusion.(1)
Many patients are asymptomatic and the disease may never be diagnosed.

The possibility of subclavian artery steal syndrome may be presented by differences in BP between both arms and unilateral diminished quality pulses.
We present a case report. Male patient that was referred to the ER because routine BP check up, he was found to have a significant BP difference between both upperextremities.

Case report
74 y/o patient, retired farmer, with no previous hospital admission. Two days ago, he had started BP treatment with enalapril 20 mg.
In routine BP control, it was found to significant BP differences in the upper extremities therefore he was referred to the ER.
In the medical history (anamnesis), he refers that since a long time ago; his left hand fingers tips are colderduring the winter when he goes farming out in the field. He never noticed neither strength diminishment, parestesias, thoracic pain nor dizziness while his arms are realizing strenuous activities.

Patient was conscious, oriented, excellent general condition. BP in the right arm: 182/72, in the left arm: 84/54
Cardiopulmonar auscultation: normal cardiac rhythm, no abnormal sounds.
Abdomen:soft, not tender to palpation
Extremities: no edemas, no trophic changes.
Neurological: normal
Peripheral pulses: there is a significant difference in the amplitude of the pulses on the left upper extremity from the axillary pulse to the radial pulse. Capillary refill is delayed in the left upper arm.
Hemogram: erythrocytes: 5.36 x 106 µL, Hct 47%, Hgb: 15.9 g/dl, MCV 88 fL, WBC 7x106 µL,...