A case of recurrent pancreatitis with subclavain artery stenosis: a clinical dilemma (unrelated co-existence or IgG4 related disease?) and a clinical lesson

We report a case of a 56-year-old woman who presented with clinical features suggestive of acute pancreatitis. She had a similar episode 5 years ago. A blood pressure (BP) recording of 80/50 mmHg in the presence of acute pancreatitis led to the diagnosis of circulatory shock and vasopressors were about to be commenced. However, her overall appearance was stable and measurement of BP in the lower limbs was normal. An angiogram revealed left subclavian artery stenosis which explained the low BP reading on left arm. The patient responded to conservative management of pancreatitis, however refused further evaluation of subclavian stenosis. This case is being reported to highlight a clinical dilemma and a clinical lesson. Dilemma arises if the pancreatitis and subclavian artery stenosis is just a coincidental occurrence or it is a case of IgG4 related disease consisting of autoimmune pancreatitis (AIP) type 1 with subclavian artery stenosis a part of extra-pancreatic manifestation of the IgG4 related disease spectrum. This distinction is important in management of pancreatitis and other organ involvement. It is important to examine a patient fully and especially the vascular system - wherein all pulses are to be felt and blood pressure recorded in both sides and both limbs - whenever there is a conflict between the condition/appearance of the patient and the signs that we elicit. In this case recognising that BP was normal in the lower limbs prevented unnecessary use of vasopressors.

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Bilateral subclavian artery stenosis found by inter-arm blood pressure difference during distal pancreatectomy

Korean Journal of Anesthesiology ◽

10.4097/kjae.2013.65.5.477 ◽

2013 ◽

Vol 65 (5) ◽

pp. 477 ◽

Cited By ~ 1

Author(s):

Do-Hun Kim ◽

Mi-Ja Yun ◽

Hyo-Seok Na ◽

Jung-Won Lee ◽

Hyo-Ju Hong

Keyword(s):

Blood Pressure ◽

Distal Pancreatectomy ◽

Subclavian Artery ◽

Pressure Difference ◽

Artery Stenosis ◽

Subclavian Artery Stenosis ◽

Blood Pressure Difference

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Refractory Hypotension as an Initial Presentation of Bilateral Subclavian Artery Stenosis

Case Reports in Cardiology ◽

10.1155/2016/8542312 ◽

2016 ◽

Vol 2016 ◽

pp. 1-3

Author(s):

Maxwell Eyram Afari ◽

John V. Wylie ◽

Joseph P. Carrozza

Keyword(s):

Blood Pressure ◽

Subclavian Artery ◽

Troponin T ◽

Right Heart Catheterization ◽

Artery Stenosis ◽

Heart Catheterization ◽

Subclavian Artery Stenosis ◽

Refractory Hypotension ◽

Left And Right ◽

The Right

Bilateral subclavian stenosis is a rare clinical condition. An interbrachial pressure difference of 15 mm Hg can raise suspicion for unilateral subclavian artery stenosis, but the diagnosis of bilateral subclavian artery stenosis can be challenging. We present a case of a 75-year-old woman who presented with refractory hypotension after surgery. Initial vitals revealed blood pressure in the 60s/50s mm Hg in both arms. Cardiopulmonary examination was remarkable for diminished pulses in all 4 extremities and audible carotid bruits. She continued to be hypotensive despite aggressive fluid resuscitation. Troponin T peaked at 0.24 ng/mL (reference < 0.04), and an echocardiogram revealed a reduction in ejection fraction (37% from 50%). Left and right heart catheterization demonstrated normal filling pressures and cardiac output. During the procedure, however, it was noted that the patient’s central blood pressure was 70–80 mm Hg higher than cuff pressures obtained in either arm. Selective angiography revealed 90% left subclavian ostial stenosis as well as 70% stenosis of the right subclavian artery.

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