Acute upper limb ischemia, a rare presentation of giant cell arteritis

Abstract

Giant cell arteritis (GCA) is a systemic large vessel vasculitis, with extracranial arterial involvement described in 10---15% of cases, usually affecting the aorta and its branches. Patients with GCA are more likely to develop aortic aneurysms, but these are rarely present at the time of the diagnosis.We report the case of an 80-year-old Caucasian woman, who reported proximal muscle pain in the arms with morning stiffness of the shoulders for eight months. In the previous two months, she had developed worsening bilateral arm claudication, severe pain, cold extremities and digital necrosis. She had no palpable radial pulses and no measurable blood pressure.The patient had normochromic anemia, erythrocyte sedimentation rate of 120 mm/h, and a negative infectious and autoimmune workup. Computed tomography angiography revealed concentric wall thickening of the aorta extending to the aortic arch branches, particularly the subclavian and axillary arteries, which were severely stenotic, with areas of bilateral occlusion and an aneurysm of the ascending aorta (47 mm). Despite corticosteroid therapy there was progression to acute critical ischemia. She accordingly underwent surgical revascularization using a bilateral carotid-humeral bypass. After surgery, corticosteroid therapy was maintained and at six-month follow-up she was clinically stable with reduced inflammatory markers.GCA, usually a chronic benign vasculitis, presented exceptionally in this case as acute critical upper limb ischemia, resulting from a massive inflammatory process of the subclavian and axillary arteries, treated with salvage surgical revascularization. 2174-2049Document downloaded from http://www.elsevier.es, day 15/09/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Document downloaded from http://www.elsevier.es, day 15/09/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 237.e2L. Almeida-Morais et al. PALAVRAS-CHAVEArterite de células gigantes; Isquemia crítica dos membros superiores; Bypass carótido-umeral Isquemia crítica dos membros superiores, uma apresentação rara de arterite de células gigantes Resumo A arterite de células gigantes (ACG) é uma vasculite de grandes vasos, com envolvimento extracraniano em 10-15% dos casos, afetando preferencialmente a aorta e os seus ramos. Os aneurismas da aorta ascendente são mais frequentes em doentes com ACG, mas são raros no momento do diagnóstico.Apresentamos o caso de uma doente, caucasiana, com 80 anos de idade, que descrevia dor muscular nos membros superiores, com rigidez matinal dos ombros, desde há oito meses. Nos últimos dois meses referia claudicação intermitente de agravamento progressivo, dor intensa, extremidades frias e o aparecimento de úlceras digitais. Ao exame objetivo não se palpavam pulsos radiais ou cubitais, nem se registavam valores de pressão arterial.Laboratorialmente, destacava-se anemia normocíticanormocrómica, VS de 120 mm/h e ...

Critical arm ischemia as rare presentation of giant cell arteritis

“… 9 Surgical revascularization is, therefore, rare, and only a very few cases of revascularization have been reported in which the patients had presented with critical arm ischemia requiring carotid–brachial artery bypass, as was the case for our patient. 4 , 5 , 10 Also, even when significant stenosis of the arteries is discovered, the distal tissue viability will rarely be compromised, even when ischemic symptoms, such as the loss of pulses, are present, because the gradual development of arterial narrowing will have allowed for the establishment of extensive collateral circulation. 11 …”

“…Thus, only a few surgical cases have been reported. 4 , 5 Angioplasty of the upper extremity vessels affected by GCA has resulted in frequent dissection and a high restenosis rate. 6 …”

Giant cell arteritis as unusual cause of critical arm ischemia

“…Surgical revascularization for critical ischemia of the upper extremity is seldom necessary in patients with GCA, with few reports in the literature. 7 , 8 Because our patient presented with severe resting pain, our vascular surgical team decided to perform a bypass procedure. Anastomoses are performed in disease-free segments of arteries to prevent restenosis.…”