Abstract
A 55 year old man presented to our clinic with 12 months of progressive symptoms of right retinal and right arm claudication. Medical history included smoking and hypercholestorolaemia. He did not display any symptoms on his left side, and had no constitutional symptoms.
Eye examination was unremarkable.
Examination of the upper limbs revealed a blood pressure discrepancy: SBP was 25mmHg higher in the right arm. There was no palpable radial pulse on the right arm, with no other evidence of vascular compromise. The rest of the neurological examination was unremarkable.
Work-up showed no abnormalities in blood tests, and a CT angiogram revealed a transverse web-like filling defect of the right brachiocephalic artery, causing severe stenosis, with associated calibre reduction of the right common carotid, internal carotid, and vertebral arteries.
Treatment with aspirin and atorvastatin was commenced, and the patient underwent angioplasty and stenting of the lesion. After stenting his symptoms or retinal and arm claudication resolved, his radial pulse has returned and his blood pressure discrepancy has gone.
Brachiocephalic stenosis is rare, and the most common cause is atherosclerosis. Manifestations include thromboembolism as well as haemodynamic compromise, and can involve any combination of carotid, vertebral and subclavian arterial territories. Brachiocephalic stenosis can lead to steal phenomenon, with symptoms of vascular compromise of the left sided subclavian, vertebral of carotid vessels. Endovascular treatment for brachiocephalic stenosis has a high rate of technical success, but patients need close monitoring post-operatively as restenosis can occur.
