Hypotension in the high-dependency unit: a conundrum

Description

A 62-year-old man was admitted with dizziness while walking on the beach. He had significant headaches and cough and phlegm for a week. In the hospital he had shortness of breath and dizziness on walking to the toilet and back. The patient's medical history included chemotherapy and radiation to the neck for Hodgkin's lymphoma with no recurrence. Clinical assessment showed hypotension in the upper limbs and right carotid bruit. Initial treatment included intravenous antibiotics and aggressive fluid management. A CT pulmonary angiogram excluded pulmonary embolus. Clinically he looked well with good urine output. Blood pressure in the legs was normal. Bilateral upper limb occlusive disease was suspected which was confirmed on arch aortogram (figure 1). This showed a complete occlusion of left subclavian, patent right and left common carotid with occlusion of right and left external carotid arteries and preocclusive lesion at origin of the right subclavian artery. He underwent successful right subclavian angioplasty with symptomatic improvement.

Figure 1.

Arch aortogram showing bilateral occlusion of subclavian arteries.

Investigations for arteritis and lipid profile were normal. We suspect radiotherapy in addition to smoking and diabetes contributed to the current occlusions.

Unilateral subclavian stenosis is a common site for upper limb arterial disease. Bilateral subclavian stenoses is very rare with less than 10 cases in the English literature.^{1 2} With occlusion of the subclavian arteries, there is reverse flow in the right and left vertebral, stealing blood from the Circle of Willis resulting in symptoms of dizziness.

Learning points.

• Low blood pressure in both arms should prompt checking the lower legs especially when a patient has normal urine output.

• Radiotherapy can induce arteritis and vascular occlusions.