Pseudo-hypotension with acute pulmonary oedema due to simultaneous bilateral subclavian artery stenosis in a patient with coronary artery bypass graft surgery using bilateral internal mammary arteries: a case report

Hirata, Kazuhito; Nakazato, Jun; Wake, Minoru; Takahashi, Takanori

doi:10.1093/omcr/omz038

Cited by 1 publication

(3 citation statements)

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“…SAS is a form of upper extremity PAD which should be suspected when exam findings reveal a BP differential of 15 mmHg or more in the arms [ 5 , 6 ] , especially in patients with known lower PAD. Atherosclerosis has been identified as the most frequent cause, followed by fibromuscular dysplasia, compression syndrome and Takayasu arteritis [ 2 , 7 ] . The pathophysiology of atherosclerotic SAS has been described as a process of cell adhesion: inflammatory cells attaching to the arterial wall, with arterial wall remodelling and lipid accumulation resulting in calcification.…”

Section: Discussionmentioning

confidence: 99%

“…When bilateral subclavian arteries are stenosed, the difference in upper extremity BPs may be concealed, making comparison to lower extremity BP measurements, as seen in tests such as ABIs, critically important. Though the ABI test is not validated in longitudinal studies, it has been utilized to diagnose bilateral SAS in previously reported cases [ 2 ] . If there is suspicion for SAS but comparison of bilateral upper extremity BP measurements is unrevealing, an ABI showing higher-than-normal values (ABI >1.3) can prompt the provider to investigate for bilateral SAS, and consider more conclusive testing.…”

Section: Discussionmentioning

confidence: 99%

“…Rarely, bilateral SAS has presented as pseudo-hypotension. In a case described by Hirata et al, bilateral SAS was misdiagnosed as cardiogenic shock [1][2][3] . In the setting of severe vascular stenosis and refractory shock of unknown origin, the index of clinical suspicion for pseudoshock should be raised.…”

Section: Introductionmentioning

confidence: 99%

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Pseudoshock: A Challenging Presentation of Bilateral Subclavian Artery Stenosis

Nasrullah

Singh

Hamza

et al. 2022

European Journal of Case Reports in Internal Medicine

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Introduction: Subclavian artery stenosis (SAS) is a manifestation of peripheral artery disease (PAD). Presentation varies, ranging from arm claudication and muscle fatigue to symptoms which reflect vertebrobasilar hypoperfusion, among which are syncope, ataxia and dysphagia. Although rare, severe bilateral SAS can exist and present as refractory hypotension. We describe a case of bilateral SAS masquerading as circulatory shock, or rather ‘pseudoshock’. Case Description: A 59-year-old female patient presented to the emergency department with complaints of dark stools. She was anaemic and hypotensive and therefore suspected to have an acute gastrointestinal bleed (GIB) with resultant haemorrhagic shock. Her hypotension was unresponsive to fluid resuscitation and blood transfusions. Bilateral upper extremity radial artery catheters confirmed low blood pressures. After her blood pressure failed to improve despite the addition of several vasopressors, a femoral artery catheter (FAC) was placed, which revealed significant hypertension discordant with the hypotension measured by the radial artery catheters. Review of CT angiography of the upper extremities revealed the presence of bilateral SAS which was deemed to be the aetiology of the falsely low blood pressure. Discussion: SAS should be suspected in patients with lower extremity PAD or a blood pressure (BP) differential of 15 mmHg or more between arms. When bilateral subclavian arteries are stenosed, this difference in BP may be concealed, making lower extremity BP measurements, as seen in non-invasive tests such as ankle brachial index (ABI) tests or through more invasive procedures such as FAC placement, critically important. Conclusion: Bilateral SAS may present as pseudo-hypotension. In cases of refractory shock of unclear aetiology, especially in patients with known PAD, a high index of suspicion is warranted for ‘pseudoshock’ secondary to severe vascular stenosis. Comparison of upper and lower extremity BP via invasive arterial catheters or non-invasive ABI tests can aid in the diagnosis of bilateral SAS.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%