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CASE REPORT
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 248-250

Left subclavian artery dissection: A mimicker of aortic dissection


Richmond University Medical Center, New York, USA

Date of Submission13-Mar-2020
Date of Decision27-Mar-2020
Date of Acceptance06-Apr-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Muhammed Atere
Richmond University Medical Center, 355, Bard Avenue, Staten Island, NY 10310, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_32_20

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  Abstract 


Subclavian artery dissection is an uncommon condition, with only a few cases reported in the medical literature. Reported cases have been due to traumatic, nontraumatic, and iatrogenic etiologies. The exact incidence or prevalence in the society remains unclear, and the cases reported are sporadic. Diagnosis is usually with computed tomography. The management usually depends on whether there is ischemia of the tissues supplied by the subclavian artery. Our objective is to present a patient who was diagnosed with nontraumatic subclavian artery dissection but presented with clinical features of aortic dissection prompting a further diagnostic investigation.

Keywords: Aortic dissection, chest pain, subclavian dissection


How to cite this article:
Atere M, Kalinga H, Al-Ataby H, Gala B. Left subclavian artery dissection: A mimicker of aortic dissection. Curr Med Issues 2020;18:248-50

How to cite this URL:
Atere M, Kalinga H, Al-Ataby H, Gala B. Left subclavian artery dissection: A mimicker of aortic dissection. Curr Med Issues [serial online] 2020 [cited 2020 Oct 29];18:248-50. Available from: https://www.cmijournal.org/text.asp?2020/18/3/248/289416




  Introduction Top


Dissection of the arteries often develops in the aorta. Dissections in other locations are less common, particularly subclavian artery dissection, which may be incidentally discovered on some occasions. Traumatic and nontraumatic causes have been documented in the literature.[1],[2],[3] However, only a few case reports delineating this condition have been reported. Various clinical features manifest such as pain around the neck to symptoms of an acute cerebrovascular accident. Diagnosis is usually done by computed tomography angiography (CTA) and treatment depends on vascular compromise or whether it is traumatic or nontraumatic in etiology. Our case describes a unique scenario because it mimicked an aortic dissection based on some of the clinical symptoms and findings. Here, we present the case of a patient with nontraumatic chest pain and upper extremity differential systolic blood pressure of >20 mmHg but the radiological evidence revealed dissection of the left subclavian artery.


  Case Report Top


A 61-year-old woman and former smoker presented with a past medical history of hypertension, hyperlipidemia, triple-vessel coronary artery disease, non-ST elevation myocardial infarction with prior cardiac catheterization nine months earlier, pericardial effusion, pituitary microadenoma, hypothyroidism, and gastroesophageal reflux disease. She came to the emergency room with a tightening-like chest pain that radiated to her neck and left arm. She denied recent chest trauma, palpitations, shortness of breath, or a cough. En route to the emergency room, she was given aspirin and nitroglycerin by the emergency medical technicians. Her vitals were within normal limits except for a blood pressure of 190/100 mmHg. The patient's brachial and radial pulses were palpable and there was no physical examination evidence suggesting ischemia in the left upper extremity. The rest of the physical examination was unremarkable: heart sounds and breath sounds were normal, and neurological examination was insignificant. Due to the possibility of an acute aortic dissection, the blood pressure was measured in both arms. The difference in the systolic blood pressure was 61 mmHg. An urgent CTA of the chest was done, which indicated a localized dissection of the proximal left subclavian artery beginning approximately 9 mm beyond its origin and extending for approximately 1.9 cm without an associated hematoma [Figure 1]a, [Figure 1]b, [Figure 1]c. No other arterial pathology was evident on the CTA of the chest. In addition, troponin was negative, and other laboratory values showed a hemoglobin of 10.2 g/dL and a pro-B-type natriuretic peptide of 4021 pg/dL.
Figure 1: (a) A CTA of the chest: Green arrow showing left subclavian artery dissection. (b) A CTA of the chest: Green arrow showing left subclavian artery dissection. (c) A CTA of the chest (coronal view): Green arrow showing left subclavian artery dissection.

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Her home medication of nifedipine of 30 mg/day was increased to 60 mg/day and atorvastatin was increased from 40 mg/day to 80 mg/day, but she was continued on the same dose of metoprolol succinate and ranolazine as recommended by the cardiologist. She was hospitalized for a total of two days and remained asymptomatic throughout her admission. Of note, the patient was also seen by the vascular surgery team, who recommended conservative medical management without surgical intervention. She was discharged home to follow-up with her primary care physician, vascular surgeon, and cardiologist as an outpatient, but she missed her appointments.


  Discussion Top


The left subclavian artery originates directly from the aortic arch. Anatomic pathologies, although rare, may manifest, including a dissection. Subclavian artery dissection may be secondary to trauma or discovered incidentally. Iatrogenic and spontaneous causes have also been described in the medical literature. However, only a few cases of subclavian artery dissection have been reported. In one case report by Chon et al., the patient developed subclavian artery dissection as a result of a fracture of the clavicle.[1] In another case report by Marik and Mclaughlin, it was incidentally identified without recent trauma.[2] Iatrogenic etiologies immediately following a procedure have also been documented. Collins et al. described the case of a 42-year-old man who underwent a diagnostic cardiac catheterization.[4] Nontraumatic dissections of the arteries, particularly in the aorta, are generally associated with hypertension, hypertension and cigarette smoking.[5]

Depending on the affected subclavian artery symptoms may vary. Sudden onset of pain in the left area of the neck and left shoulder may occur.[2] Other manifestations include arm fatigue and numbness and a diagnosis of acute cerebrovascular accidents and even sudden death.[6],[7],[8],[9] Dissection of the subclavian artery may extend to its branches like the brachial artery.[9] Diagnosis is usually by imaging, often with a CTA, but it can also be diagnosed with an ultrasound depending on the location of the dissection.[3] The management depends on the etiology and the clinical scenario that led to the dissection. Vascular compromise or life-threatening manifestations may prompt surgical interventions. Reconstructive surgery and placement of graft are performed in patients who run the risk of decompensating or patients with blunt trauma to the chest wall.[10],[11] Some patients may be managed conservatively without surgery, particularly if they are clinically stable or if there is no vascular compromise.[2],[6],[7],[8],[12]

Our patient presented with chest pain with radiation to the neck and left arm. Her presentation initially pointed to acute coronary syndrome. Further clinical evaluation was suggestive of a possible acute aortic dissection, particularly with a difference in systolic blood pressure of 61 mmHg. A CTA instead denoted a left subclavian artery dissection. We are uncertain of the provoking factors, but we believe that a history of hypertension, hyperlipidemia, and a prior history of cigarette smoking may have contributed to the incidental finding of a dissection. A prior history of cardiac catheterization may have also played a role, but there was no documented evidence of complications or persistent symptoms during and after the procedure, and the right radial artery was the cannulation site during the procedure 9 months earlier. Our patient was seen by the vascular surgeon during hospitalization, but they recommended conservative management of risk factors that may be potentiating the dissection of the left subclavian artery. There are no specific guidelines that assist physicians in managing such patients or in providing regular monitoring in unruptured types. However, blood pressure control and statins may prevent the worsening of the dissection. Our patient was managed for her risk factors to hinder the progress of the dissection of the left subclavian artery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chon S, Yie K, Kang JG. Traumatic subclavian artery dissection in clavicle fracture due to blunt injury: Surgery or stent in long segment occlusion? J Trauma Inj 2015;28:219-21.  Back to cited text no. 1
    
2.
Marik PE, Mclaughlin MT. Spontaneous subclavian artery dissection: A pain in the neck diagnosis. BMJ Case Rep 2013;2013:bcr2013201223. Published 2013 Nov 21. doi:10.1136/bcr-2013-201223.  Back to cited text no. 2
    
3.
Onishi H, Yamamura O, Matsuo S, Tanaka T, Daitoku S, Konokawa S, et al. Localized right subclavian artery dissection detected by accident on an ultrasound examination: A case report and literature review. Intern Med 2019;58:73-8.  Back to cited text no. 3
    
4.
Collins NJ, Beecroft JR, Horlick EM. Complex right subclavian artery dissection during diagnostic cardiac catheterization. J Invasive Cardiol 2008;20:E61-3.  Back to cited text no. 4
    
5.
Gawinecka J, Schönrath F, Eckardstein A. Acute aortic dissection: Pathogenesis, risk factors and diagnosis. Swiss Med Wkly 2017;147:W14489.  Back to cited text no. 5
    
6.
Winblad JB, Grolie T, Ali K. Subclavian artery dissection. Radiol Case Rep 2012;7:626.  Back to cited text no. 6
    
7.
Jeon K, Cho H. Spontaneous subclavian artery dissection presenting as posterior circulation infarction. J Neurocrit Care 2017;10:116-21.  Back to cited text no. 7
    
8.
Funada A, Ino H, Fujino N, Hayashi K, Uchiyama K, Masuta E, et al. Idiopathic dissection from left subclavian artery to brachial artery: Spontaneous repair with conservative management. J Cardiol Cases 2010;1:e49-51.  Back to cited text no. 8
    
9.
Majdoub W, Mosbahi A, Beji M, Sriha B, Turki E. A case of sudden death due to spontaneous right subclavian artery dissection. Forensic Sci Med Pathol 2017;13:518-21.  Back to cited text no. 9
    
10.
Henderson RA, Ward C, Campbell C. Dissecting left subclavian artery aneurysm: An unusual presentation of coarctation of the aorta. Int J Cardiol 1993;40:69-70.  Back to cited text no. 10
    
11.
Günday M, Ozülkü M, Yıldırım E, Güven A, Ciftçi O. Successful endovascular treatment of subclavian artery dissection after compression trauma. Am J Emerg Med 2013;31:457.e1-3.  Back to cited text no. 11
    
12.
Palop RL, Carrillo P, Frutos A, Cordero A. Conservative management of iatrogenic subclavian artery dissection during a percutaneous coronary interventional procedure. Rev Esp Cardiol 2011;64:833-4.  Back to cited text no. 12
    


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