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.

Prevalence of Subclavian Artery Stenosis in Patients With Coronary Artery Disease

Background : Atherosclerosis is the most common and serious vascular disease that affects both the brain and the heart .(1) Subclavian stenosis/occlusion is a marker for atherosclerotic disease (eg, carotid, coronary & lower extremity arteries) and future adverse cardiovascular events. (2) In this study, we identified the prevalence of subclavian artery stenosis in patients presented with coronary artery disease (CAD) through changes in the Doppler tracing of vertebral arteries that appear to represent a clue of subclavian artery stenosis.Methods: On the basis of extracranial Doppler ultrasound & supplementary intracranial Doppler ultrasound, we assessed the pattern of Doppler waveform in both carotid & vertebrobasilar systems among 100 consecutive patients who were hospitalized for CAD in the cardiovascular department.Results: Among 100 consecutive CAD patients studied, we identified stenosis and occlusion of subclavian artery in 5 patients (5%). In those patients, subclavian arterial disease was indirectly discovered by changes in Doppler waveforms of vertebral artery. Conclusions: Prevalence of subclavian artery stenosis in patients with CAD is 5%. Changes in the pulse contour of antegrade vertebral artery Doppler waveforms seem to represent a good screening method for subclavian steal phenomena.

Subclavian steal syndrome without Stenosis: A Case Report and Review of the Literature

Background："Stealing" of the subclavian artery is a phenomenon where proximal subclavian artery stenosis or occlusion causes retrograde blood flow in the ipsilateral vertebral artery. This, combined with ischemic symptoms of vertebrobasilar arteries or ipsilateral upper limb artery, is called subclavian steal syndrome. Sometimes, subclavian steal syndrome can occur in patients without subclavian artery stenosis, such as in patients with high-flow arteriovenous dialysis fistulas or subclavian artery aneurysms. Interestingly, compared with classic atherosclerotic subclavian steal syndrome, the former patient is more prone to symptoms like paroxysmal vertigo, drop attacks, diplopia, and arm claudication. Case Presentation ： In our case, we present a 35-year-old male who suffered from paroxysmal vertigo. Clinical physical examination did not reveal any substantial evidence of proximal subclavian artery stenosis. Transcranial Doppler and ultrasonography revealed an abnormal blood flow pattern in the right vertebral artery, consistent with partial subclavian steal syndrome. Ultrasonography and computed tomography angiography showed no stenosis in the right subclavian artery and three aneurysms in the proximal segment. The hypoplastic vertebral artery originated from the third aneurysm. Conclusions ： There are few reports of subclavian steal syndrome caused by subclavian aneurysms in the literature; our case is the first to report partial subclavian steal syndrome caused by multiple aneurysms. Following a literature review, combined with our analysis of this case, we suggest that subclavian artery aneurysm which induced subclavian steal syndrome is an often unnoticed cause of vertigo.