Imaging Challenges in the Diagnosis of Anatomical Variations of the Supra-Aortic Vessels: A Case Report and Review of Literature

A 73-year-old woman was referred to our Cardiology Department due to recurrent headaches and dizziness. She had a history of hypertension of 10 years. In the territorial hospital, left internal carotid artery significant stenosis was suspected. Neurological examination and laboratory tests were normal. A neck vascular ultrasound was performed, showing a low bifurcation of the left common carotid artery (CCA) and a hypoplastic left internal carotid artery (ICA) with a sinuous path at the cervical level. Therefore, a computed tomographic (CT) angiography examination of the head and neck vessels was performed. The images confirmed the presence of a hypoplastic left ICA, anatomic variation in the left CCA, and also showed that the left vertebral artery (VA) was stemming directly from the aortic arch, exhibiting a kinking trajectory.

Atypical presentation of fistula dysfunction due to brachial arterial embolization mimicking stroke

Vascular access thrombosis is an important complication with great impact on access patency and, consequently, on a patient’s quality of life and survival. We report the case of a 73-year-old woman with chronic kidney disease on hemodialysis with a radiocephalic arteriovenous fistula on the right arm that was brought to the emergency department with decreased strength in her right arm, ipsilateral hypoesthesia and facial hemi-hypoesthesia. The patient was given a brain computed tomographic scan that did not confirm suspicion of stroke. On re-examination, the patient had new-onset pain at arteriovenous fistula level, and her right arm was cold and pale. The nephrology department was called for arteriovenous fistula evaluation. On physical examination, her forearm fistula had a decreased thrill and arm elevation exacerbated its paleness. A bedside ultrasound was performed for arteriovenous fistula assessment. Doppler ultrasound revealed: partial thrombosis at brachial bifurcation, a flow of 80–105 mL/min at brachial artery level and a radial artery with a damped waveform. Anastomosis and draining vein were permeable. In this case, the diagnosis of acute embolic brachial artery occlusion was made by a fast bedside ultrasound evaluation. The patient underwent thromboembolectomy with Fogarty technique, recovering fistula thrill, radial and cubital pulses. Thromboembolism of the fistula feeding artery is a rare cause of vascular access thrombosis and it is rarely mentioned in the literature. In this report, failure to recognize the upper limb ischemia would have led to delayed treatment, potentially resulting in the fistula’s complete thrombosis and further limb ischemia. We highlight the importance of a diagnosis method like Doppler ultrasound, which allows for rapid evaluation at the patient’s bedside.