So um I have been tasked with trying to stump our expert. This is a challenging task to be sure and for no other reason because, Well I mean our experts are experts, which means they're hard to stop, right but also because they are involved in most of the cases of the more challenging cases that are going on in any of our institutions and to find something that none of them knows anything about is really really challenging. It's been a long day and time is short. But I have a couple of cases that I can present that at least will present you with a dilemma either in terms of diagnosis or management of the problem and we'll see what our panelists can come up with here. So I know I can't see that either down there. Alright, so case # one, we have a 62 year old woman. She has known moderate to severe coronary artery disease and complaints of chronic angina. Pc. I was deferred for a while actually because of prayer, bleeding and transfusion dependent anemia that she had demonstrated on a prior trial of dual into platelet therapy. Her medical history is full of risk factors for atherosclerotic disease, including hypertension, diabetes, dis lipid E. Mia and obesity. At the time of her initial treatment, she was a current or within weeks former smoker and her symptoms worsened. So she underwent cabbage. This included a sequential lima graft to her diagonal in L. A. D. As well as staff in his vein grafts and she did experience clinical improvement. However fast forward three years later and her Angina symptoms returned. And so she went to cardiac catheterization. The team tried a radio left radial artery approach at first and they were unable to advance a wire sufficient enough to gain sheath access to the aorta. Using an alternative approach to the right common femoral artery was successful and they proceeded with catheterization. What they found was all her coronary bypass grafts were Peyton But she did appear to have a 70% high grade stenosis in her native mid led that appeared to be hemo dynamically significant. So the first question I guess I would ask in terms of management of this patient, here's a patient who's had bleeding problems on D. A. P. T. In the past. What do you do now dr swisher bro. We got a interventional cardiologist on our panel. Well you know I'm a little bit puzzled I have to say why couldn't they pass the wire from the left radio? Because I'm assuming the lima. You said it was patent. I'm having a hard time seeing it from here. And so um that that's still a puzzle for me that how did they get the lima? Were they able to get it from the subclavian? You know or not. But that's one thing we need to figure out and in regards to the lesion in the lady. Typically these lima's they can feel ritual great. So I do see an attachment of the lima. It's not it doesn't have a good wash out. You know, it's not the greatest lima. There's something wrong with that lima. So, we're just looking at that angiogram. I just I'm not happy with the idea that the lima is patent. I'd like to see a picture of it and I feel like it's not patents. He asked my opinion. Okay. Any other comments from anyone else? Alright. And I'm I was looking at this calf and trying to find wide, left, right, right, right radio was harvest. Um No, and I think it was because of the lima graft exactly what dr Schlossberg was saying, which you would want in a coronary angiogram for someone post bypass to make sure they're they're bypasses were all open. And I was looking for the image that actually showed that selective catheterization was not able to find it. But all the reports were that that lima bypass was Peyton. So, they did investigate why it was they were unable to pass a wire on sheet appropriately from the left subclavian artery. And this is what they found was this left subclavian artery that looks very, very torturous with a kink in the artery. There any comments about that. And what now this looks like this looks like a compression from a dissection. I mean that that kink is very abnormal for an arthroscopic inclusive lesion. And you can almost make out a kind of a double density at that. It's hard to see from this distance, but right at that kink area, Something's wrong there. And it may be where the true lumen, false lumen meat and then there's true women flow in that, in that the other thought I would have, I would wonder how her arm is being positioned at the time of the angiogram. And is this A. T. O. S we're eliciting with the arm positioning. It's a weird, weird looking lesion. Good. This is a great case. We've got some things wrong with that lima, something's wrong with that subclavian artery. So this is exactly what you want to say. Alright, so are there any first thoughts about how we would manage this or what, what do we want to see or know next? I mean, I I think you have a few tools in your armamentarium to try to, you know, kind of evaluate this artery as because we don't know what's going on. So I think dr Cornick highlighted something and then DR cash. So I think there are some imaging opportunities there is ivy's, you can either use this and understand if there is a section there, we can do some maneuvers to try to understand. Does that get better? But there are some tools available. One other point I'd make, I agree with dr hornet, that's something something we sometimes see. But I would suggest that in T. O. S. Usually the compression is a little bit further distal. Um really at that at that thoracic inlet, you would say where where you have the clavicle on the first crib overlapping. It's a little bit more distal. And I'm assuming this arm is in a abducted position. That is by the side. Which is usually when it's not compressed in T. O. S. That's a great point. And actually I can show you an image that illustrates exactly that dr chow. No, But the dressing on the syndrome to manifest itself. I think she's a little too old for that. She's 62 years old and I agree without the cache of this a little bit to proximal is usually right at the point where the water is rising. Writing over the top of the first rib of. Can you refresh my memory? The main presenting symptom was just chest pain. Wasn't angina. Was Angela Wright is a pressure differential between the two arms. That was something I was unable to identify her presentation. All right. These are all because we're learning a lot about a lot of different entities. Just one case. Okay, so of course, what do we do when we don't know what we're looking at? We go find out more about it. So in that top left panel you can see there's a colored duplex ultrasound which sort of demonstrates the artery making a tortuous bend or kink like this. And in the upper right panel you can see It's got a velocity at that point of 430 cm/s. So that's certainly a velocity shift by any by any definition. Um And then what do we do when we you know find something that we get more imaging in this C. T. A. Reconstruction Now with the arm a be deducted right um shows really a tortuous kink of that subclavian artery. And again it's not or official it's not associated with atherosclerotic material. It seems to be more tortuous city. Don't systemic the report was it was paid. Right Okay. So we have a more selective angiogram a better quality in terms of the imaging and the contrast of pacification that was done. And this gives you a lot better idea of what the anatomy is. Let's see. Can I ask dr kota describing what you see on the angiogram. Are you able to are you able to Talk about that .62.9 seconds in? That's yeah a little farther. That's yeah. Somewhere in there. But there's something wrong there. Okay. Tell me something we don't know a little further down. It looks like a little further. Yeah that's perfect right there and just just leave it there. Thanks very much. So there is some aneurysm or changes. Is that is that I don't know without the subtraction view if that there is an aneurysm or change over the subclavian artery and this is something that you're expecting somebody with dressing on the syndrome. But even even before that that is it. Is that what is that? There's a slight feeling defect right. That looks like some extrinsic compression in the approximate segment before it turns. So ah it's not right uh isolated subclavian. FMD. You might see it in Children. It's like focal disease but really weird. I think the other comment I'd make is on the duplex and the C. T. A. I don't see any wall thickening or anything intrinsic. So this is some kind of extrinsic process. Don't you wish you had walking encyclopedias like this everywhere? Alright so I think notable things in this angiogram are first of all that it appears that the the trunk or the origin the artery is somewhat enlarged as dr chou pointed out. And that's actually um I believe the take off the left vertebral artery is directly off a common origin off the aorta. So the origin is somewhat enlarged. Now you've seen an image of her with her arm completely abducted. The C. T. A. With her arm completely. A or sorry a deducted a be deducted. And now this is like something sort of in between but there's a sheath and a stiff wire that's straightening out this tortuous city as well. So it's really kind of hard to tell what it was. I guess the main question is we're not sure what it is. What are we gonna do about it? What does anyone want to do about her symptoms? Do not think you know just fix the led and leave it alone. The native lady like you know there are a couple of moderate size too severe and other inclusions in the lady? I think those can be easily extended and leave it alone. Can we go back to the reason for this? So how symptomatic is she really? Is this lifestyle limiting? And have we tried medical management to support this? I realized there's a clear anatomical problem. But if we don't have an easy fix, how urgent or important is it? We're not offering mortality benefit necessarily for this. Alright, awesome option. E so medical management was opted for um However her chest still hurts. So then we went to option but but my question is why would her chest hurt from a isolated left subclavian lesion unless it's causing that L. A. D. Graph to be inhibited. But I I thought I heard that the flow in that LED graft was okay. The report said that the lima two led was patent without stenosis. I don't think that was accurate, meaning that I think the report was inaccurate because when you look at the end of the first angiogram that you showed it was clear that there wasn't a good competitive flow in the lady which meant that there was a compromise of the dilemma. I think the other thing that would be great to see is did she have functional imaging? Did she have profusion imaging? Is there an interior wall deficits? Sorry if I missed that that I think would be helpful. All right and I don't have that information. Would it be possible to get Ct and you the ct Andrew was what you saw in the previous slide the reconstruction. It was not coronary. Alright. So they proceeded to cardiac catheterization to address the 70% led lesion because her symptoms were not better. Um And she underwent PC. I. With this is the original lesion as you see it. And you can see on the following angiogram. The stent in the L. A. D. It's very nicely placed. Her FFR reversed to normal and everything seemed very good. So that's exactly the route that the team took for this patient. So now she's on the A. P. T. She's not bleeding but the next day her symptoms have still not improved. So now what form? Yeah Dr wong what are her symptoms? Are they chest symptoms or arms symptoms or what are the symptoms? It's angina. She's very clearly describing angina pain. It's what she had before her cabbage and was relieved with her cabbage three years ago and it's the same discomfort. It's not unusual. There could be depending on the security of the subclavian region. Is it possible that you know the arm is still in blood from the lady? So that's it's it's I think it's very rare but it does. Is she left handed she is right hand dominant? Yeah it would be you know I really need to be convinced. And you know one way to know that is to look at the angiogram after the I mean looking at that Andrew after extent, I don't see a lot of flow going up the lima. But we've seen in some cases where there's subclavian occlusion and then, you know, the arm, you know, people that are left handed if they're using their arms like you know, doing artistic work or doing cleaning or those kind of things, they sometimes get angina. But I think it would be unlikely. So if we were going to go after that left subclavian lesion, tell me how you would do this. Is this, how would this lesion be approachable or treated? What would your reference be? Let me ask you one more thing is this is a symptom dependent on armed position. That's not clear history that I was able to get from this patient. So left subclavian artery stenosis. We oftentimes stent we also have a number of open surgical revascularization options. But so let's start by asking what you guys think would be the best way to treat something like that based on the anatomy you saw in the angiogram that we had. Would you step this lesion, doctor? Well, you have really stumped me because I'm still not sure what to do with this case. So thank you for this great case. But if you're asking what should be done if for that focal lesion, that's like almost a I think if you will in the proximal uh subclavian, that's a very unusual place to get an extrinsic compressive type of issue. I gather I would likely stent it. I would do it from the arm approach just like you had in that previous picture and likely I'd use a covered step. Very good. Any other opinions? Yeah, yeah, I would understand it and I think that there is a risk of fracture in that area. There's also another lot of atherosclerosis. Also there's not a good indication to fix it because the lady has been fixed. You know, maybe we need to find out why she's having chest pain. Maybe there are other causes, but I don't have a good indication to fix it. Okay, so essentially that was a that was the clinical conundrum here. Um I think the team was very interested in treating the left subclavian lesion because now the LED was treated, she was still having symptoms. The question was, was this a case of subclavian steal? But there was some hesitance to stent the lesion because of it being more of a tortuous city than a plaque, as dr Kashyap said. And it's proximity to the left vertebral origin and the origin of the lima, which of course her coronary circulation was dependent on. So this patient underwent left carotid subclavian artery bypass and experienced relief the next day. So a carotid subclavian bypass for those who are not most familiar with this is a direct bypass. As you see in this cartoon between the left common carotid artery and left subclavian artery. Beyond what is approximate left subclavian artery occlusion. Typically this is an atherosclerotic plaque spillover plaque from the aorta into the orifice of the left subclavian artery. Though that wasn't the case in this patient, but it can jeopardize. Uh It can lead to a scheme here jeopardize filling of branches distantly. The most typical presentations is that of vertebral basilar insufficiently or vertebral basilar symptoms, particularly with the use exertion of the bilateral arm because of increased demand and then not being able to supply an a grade flow to that limb because of the obstruction. Our patient didn't have that because her left vertebral artery came off the aorta more approximate to that. She never had vertebral basilar insufficiency. This cartoon here shows you a little bit more specifically this situation in this patient where she had Alima which was a distal distal branch to the obstruction and resulted in a reversal flow from that graft causing the coronary ischemia. Yes, dr turner, right, right. I mean I think that you know if you felt that this was you know if you felt this was a steal from the army. And the other option would have been to just call em belies the lima because it's not really functioning anymore. The lima is really you fixed the native led. We don't need that bypass graft anymore. It was a sequential lima also to the diag so I don't know if it was still helping the diag so I don't know how I didn't pay that much attention to the diet. But you know but you know if you took care of the natives you could argue that you know you could call the you know dilemma. Good point. Good question. Alright so the image that I did not show you was obtained at the time of the coronary stenting. So you can see the L. A. D. Stent. They're pretty carefully and this I slowed down a bit. Who can tell me what's going on in this picture Patient was asked to exercise her left hand on the table for three minutes before this injection dR system. Or that's that's what we were talking about this. That's it. That's the steel. Does everybody see that? So the guy is going up the lima up to the subclavian artery that's going all the way up to there arm. So that's the that's what we're talking about. But it really shows that the lesion in the subclavian is severe. That atrocity whatever it is is pretty severe to atrocity because you shouldn't be getting die going up like that. Probably my dr hart. Do you have a question direction? It was off it was anti grade but it was off the aorta. So as expected. Right So yes so that's exactly that's exactly what this was and I think that this is a perfect example of a patient can have as many diseases as she pleases. And it just took us a bit to knock off the possible causes one by one until we got there. So, which journal is this image going to? It's beautiful. It's a beautiful image and it tells a really interesting, rare but important to think about story. Right. Absolutely. Yeah. Good. Alright. Let's raise the importance of doing a physical exam with blood pressure measurement and post. So I was able to find differential blood pressure. They were equal post but I was not able to find any that were dedicated left and right arm pre that I could actually, I was told was different. So All right. Do we have time for one? Okay, so one last one and then uh and then we'll be concluded for the day. Alright. This is a case of a 69 year old right hand dominant woman who presented to the emergency department with a painful blistered right hand. The blisters are what began first several days ago and steadily worsened And the day she presented, she woke up with the sudden onset of white cold fingers. Her past medical history is as described there and she's on several meds that you might expect her to be on for those same medical problems. She was a never smoker. She had been widowed since the year 2000 estranged from her daughter and did not wish her son contacted on the day of admission, there's no family history of autoimmune disease or VT. This is what her hands looked like. Right hand. Volar and dorsal surfaces and you can actually see in the top left. So excuse me, the top right picture. Her normal left hand is actually in the background. Her left hand, her both lower extremities were normal. The right hand was had demarcation, very white at the interface. Longo joints where the fingertips were insensate without capillary refill. She had these blisters which were in various stages of of draining that one on the palm had drained and was flattened to serious fluid. She had palpable pulses in the break your radio and ulnar locations on that side. And Doppler signal was present at her palmer arch, in in the base of digits two through five. What does the panel make of this calling dR Carmen stat console. Mhm. That's exactly right. What were the inciting events? Was she exposed to court or I mean, did she have any history of any sort of a splinter hemorrhage or weakness, fertig ability? What were any other history? Excellent. Alright. So let's get some more history. So specifically asked and she denied a history of trauma. Fall burn, Cold exposure, insect bites, chemical exposure, sick contacts, recent febrile illness, G. I. Or G. U. Complaints. And she herself had no history of VT autoimmune or visa spastic other than the fingers. If you just look to her hand the palm it almost looks like a first degree burn doesn't it? With blistering. But when you look at the fingers that's very abnormal. I mean this is you've got some good cases here. Dr wong. You must have searched for the last six months for these cases I would say. I mean I think this is a this is very worried so its unilateral. I assume the other side was okay and it seems like it's a small vessel process. I think this is one thing I like to teach my fellows is to get the pulse oximeter right in the er and you can actually get tracings on those digits. I mean by the look of it they're not refusing. So it's some kind of ischemic process with some kind of epidermal ISIS. That's how I guess I describe it but I'm no closer to an answer. Dr Barnes. Yeah my my only other thought was I would ask her about meds and other exposures. Although you would expect that to be bilateral. Um And so I I I agree that there's something happened in that hand and I'm I'm profoundly moved by the ischemia of the digits with that cut off combined with the swelling and and blistering of that hand. The only case I've ever seen that's similar to this is when I was in the military and unfortunately a patient that was not a military hospital in a community civilian hospital got a instead of an I. V. And intra arterial injection of I think it was epinephrine or it may have been more happy and had a hand like this. But this is 20 years ago and that was clearly a traumatic you know estrogenic problem. All right so let's get some more information then. So emergency department labs. Basic panels were all within normal limits except for a deed. I'm er that was somewhat elevated at just over 5000 100 paddock panels said rates crp you a all normal except for some mild chronic kidney disease drugs. Green covid 19 tests are all normal. Yes. Can can she recount for us hour by hour her last week. I mean something happened that that really set this off and I think you just you know med students going to dig into this like none other to really find that or or an infectious disease dot because they're both about equally thorough. The most complete consult in the hospital. Right. All right. Any other laboratory tests or imaging studies? What what what else would we where else should we go from here? Worker inflammatory markers. They were normal. They were have not been ordered yet. Okay. Okay. Because I think that would be interesting. But I think really taking a history any trauma cold X. You know did she immerse her hand in something or she said her son or when we don't know what's going on and we think it's a vascular issue. Where do we go? We go to the vascular lab. So you guys will tell us exactly what's going on. Right. She had a venus duplex, it was negative for dvt she had upper extremity PBRS and she had normal risk particular industries which you might expect because she had palpable pulses at that level and dampening of her way forms through digits three suits through five. So that was not all that informative. Um You mentioned laboratory autoimmune markers, What would you like to see dr garnett? I mainly want to see the basic and like crp and said right just is their tissue losses? She inflamed they were normal? It looks like she might I mean it looks like she might have arthritis. Does she have rheumatoid arthritis? Or what kind of markers would you order for that? What would you expect to see? Well it just doesn't look like a rheumatoid. Her hand looks arthritic, it looks like she has rheumatoid arthritis? Just the deviation. So maybe rheumatoid factor A. And a but I'm not sure that's the process. Okay, what else would be on our differential? Is this still vascular? Is this still a vascular problem? So the only the only other thing and this is not, I mean this doesn't fit the phenotype but you have usually younger males that use their hands to do mechanical activity and you get hypothermia Nordheimer syndrome? But that is again it's in the right digit distribution that's usually embolization complete, you know, complete white fingers from from a lab standpoint. Did anyone check cryo globulin? Okay so we're starting to move down less common types of things and but of course we have to get advanced imaging right because that's what we do. So she did also have a C. T. A. That demonstrated her major arteries actual arteries were patent to the palmer arches. Although there was a minor beaded appearance called in the distal radial and ulnar arteries though. Um Not not a hard call just it's hard to see it on the record. Well I will say um I want to say I'm glad you put that other because beating has a differential. Okay so not all that is Beated as FMD dissection that heals vasculitis. So in this case I would be more worried about vasculitis than FMD but I always think about FMD. How do we work up vasculitis then? What would be what what would be the next move? A ton of labs in rheumatology? I mean no it's like honestly it's it's a bunch of labs that you just start piecing together because none of them have, you know is definitive for one and and so you sort of go down that A N A N A. You know the whole pathway of pick pick a bunch of letters and put them together alright. Which of course we did and they were all negative and she had an echocardiogram. In fact it was even A. T. E. Looking for any evidence of thrombosis or vegetation that also was normal. This this is not all done in a couple hours. How are those fingers doing? I mean you're you're you're a ways into this work up process. Where are her fingers going? How are they refused the right doctor? No they have not gotten any better. So on hospital day five we are now the team calls the patient's son to get more history and your comment about it being the medical student is spot on. So at her home after admission the son discovered a tea kettle on the stove and a bowl of ramen soup nearby on the counter. He also reports that he thinks his mom has had some selective memory and has been known to omit or forget details in the past. So when confronted with this information the following day the patient admitted to the team that she may have touched the kettle or the soup with her right hand but she really cannot recall for sure. And you're asking this had to be event. How could you not know that something happened? And she actually could not recall that. She may have done this. So yes the diagnosis in the end was a thermal injury. It was a thermal injury or burn but also and probably significantly so some cognitive impairment and memory loss that actually was so well compensated for. And she had managed to hide this from just about everyone. Um she did eventually demarcate and ended up losing digits two through 5 at the p. i. p. joint. No. Very good. You guys did think right down? Yes. No. That's it, wow, fantastic. Okay. First of all the first messages, thank you all for a wonderful afternoon, thank you for the speakers uh for doing a great job in the moderators and thank you for all of you joining us today.