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Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial embolism: the Pitcher Syndrome'

Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial... 2782 G. Lee et al. 32. Jalife J, Berenfeld O, Skanes A, Mandapati R. Mechanisms of atrial fibrillation: 37. Rajappan K, Kistler PM, Earley MJ, Thomas G, Izquierdo M, Sporton SC, mother rotors or multiple daughter wavelets, or both? J Cardiovasc Electrophysiol Schilling RJ. Acute and chronic pulmonary vein reconnection after atrial fibrillation 1998;9:S2–S12. ablation: a prospective characterization of anatomical sites. Pacing Clin Electrophy- 33. Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, siol 2008;31:1598–1605. Khunnawat C, Ngarmukos T. A new approach for catheter ablation of atrial fibril- 38. Cheema A, Dong J, Dalal D, Marine JE, Henrikson CA, Spragg D, Cheng A, lation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004;43: Nazarian S, Bilchick K, Sinha S, Scherr D, Almasry I, Halperin H, Berger R, 2044–2053. Calkins H. Incidence and time course of early recovery of pulmonary vein con- 34. Schauerte P, Scherlag BJ, Patterson E, Scherlag MA, Matsudaria K, Nakagawa H, duction after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol Lazzara R, Jackman WM. Focal atrial fibrillation: experimental evidence for a 2007;18:387–391. pathophysiologic role of the autonomic nervous system. J Cardiovasc Electrophysiol 39. Echahidi N, Pibarot P, O’Hara G, Mathieu P. Mechanisms, prevention, and 2001;12:592–599. treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2008;51: 35. Roberts-Thomson KC, Stevenson IH, Kistler PM, Haqqani HM, Goldblatt JC, 793–801. Sanders P, Kalman JM. Anatomically determined functional conduction delay in 40. Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC, the posterior left atrium relationship to structural heart disease. J Am Coll Pettersson GB, Blackstone EH. Atrial fibrillation after lung transplantation: timing, Cardiol 2008;51:856–862. risk factors, and treatment. Ann Thorac Surg 2007;84:1878–1884. 36. Sauer WH, McKernan ML, Lin D, Gerstenfeld EP, Callans DJ, Marchlinski FE. Clini- 41. See VY, Roberts-Thomson KC, Stevenson WG, Camp PC, Koplan BA. cal predictors and outcomes associated with acute return of pulmonary vein con- Atrial arrhythmias after lung transplantation: epidemiology, mechanisms at duction during pulmonary vein isolation for treatment of atrial fibrillation. Heart electrophysiology study, and outcomes. Circ Arrhythm Electrophysiol 2009;2: Rhythm 2006;3:1024–1028. 504–510. doi:10.1093/eurheartj/ehq269 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 30 July 2010 ............................................................................................................................................................................. Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial embolism: the ‘Pitcher Syndrome’ 1 2 1 Daniela Reutter , Roger Hunziker , and Marc Husmann * 1 2 Clinic for Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; and Department of Radiology, University Hospital Zurich, Zurich, Switzerland * Corresponding author. Tel: +41 44 255 3491/+41 44 255 2650, Fax: +41 44 255 4510, Email: marc.husmann@usz.ch Embolic brachial artery occlusion most often originates from the heart, the aortic arch, or from subclavian artery aneurysms. A 64-year-old man presented with acute upper limb ischaemia of the left arm. Duplex sonography confirmed a brachial artery occlusion, but no com- pression of the left subclavian artery or a subclavian aneurysm as source for the emboli. There were no signs for cardiac arrhythmia in the ECG nor cardiac thrombus by echocardio- graphy. Computed angiogram of the thoracic and upper extremity revealed an aneurysm of the left posterior circumflex humeral artery (Panels A and B). Treatment con- sists in surgical embolectomy at the brachial bifurcation and in ligation of the aneurysm. Aneurysms of the posterior circumflex humeral artery have been reported for volleyball and baseball players and named as the ‘Pitcher Syndrome’. Repetitive traumas to the arterial wall during throwing motions of the shoulder affect the posterior circumflex humeral artery at the quadrangular space at the neck of the humerus. Embolic occlusion may result from dislocation of the squeezed thrombus from the aneurysmatic sack during shoulder movements. Since this patient did never practice any other sports than yoga, it might be assumed that certain specific yoga exercises with shoulder movements might have provoked the artery trauma. The absence of cardiovascular source for thrombo-embolism by echocardiography, ECG, and vascular sonography demands additional vascular imaging that allows an entire vascular assessment to detect rare sources for embolism. Panel A. Three-dimensional volume rendering computed tomography image. Aneurysm of the left posterior circumflex humeral artery (white arrow) and thromboembolic occlusion of the left brachial artery bifurcation (white arrowhead). Panel B. Transverse computed tomography image. Aneurysm of the left posterior circumflex humeral artery (white arrow). Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial embolism: the Pitcher Syndrome'

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References (10)

Publisher
Oxford University Press
Copyright
Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2010. For permissions please email: journals.permissionsoxfordjournals.org
Subject
CARDIOVASCULAR FLASHLIGHTS
ISSN
0195-668X
eISSN
1522-9645
DOI
10.1093/eurheartj/ehq269
pmid
20705697
Publisher site
See Article on Publisher Site

Abstract

2782 G. Lee et al. 32. Jalife J, Berenfeld O, Skanes A, Mandapati R. Mechanisms of atrial fibrillation: 37. Rajappan K, Kistler PM, Earley MJ, Thomas G, Izquierdo M, Sporton SC, mother rotors or multiple daughter wavelets, or both? J Cardiovasc Electrophysiol Schilling RJ. Acute and chronic pulmonary vein reconnection after atrial fibrillation 1998;9:S2–S12. ablation: a prospective characterization of anatomical sites. Pacing Clin Electrophy- 33. Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, siol 2008;31:1598–1605. Khunnawat C, Ngarmukos T. A new approach for catheter ablation of atrial fibril- 38. Cheema A, Dong J, Dalal D, Marine JE, Henrikson CA, Spragg D, Cheng A, lation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004;43: Nazarian S, Bilchick K, Sinha S, Scherr D, Almasry I, Halperin H, Berger R, 2044–2053. Calkins H. Incidence and time course of early recovery of pulmonary vein con- 34. Schauerte P, Scherlag BJ, Patterson E, Scherlag MA, Matsudaria K, Nakagawa H, duction after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol Lazzara R, Jackman WM. Focal atrial fibrillation: experimental evidence for a 2007;18:387–391. pathophysiologic role of the autonomic nervous system. J Cardiovasc Electrophysiol 39. Echahidi N, Pibarot P, O’Hara G, Mathieu P. Mechanisms, prevention, and 2001;12:592–599. treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2008;51: 35. Roberts-Thomson KC, Stevenson IH, Kistler PM, Haqqani HM, Goldblatt JC, 793–801. Sanders P, Kalman JM. Anatomically determined functional conduction delay in 40. Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC, the posterior left atrium relationship to structural heart disease. J Am Coll Pettersson GB, Blackstone EH. Atrial fibrillation after lung transplantation: timing, Cardiol 2008;51:856–862. risk factors, and treatment. Ann Thorac Surg 2007;84:1878–1884. 36. Sauer WH, McKernan ML, Lin D, Gerstenfeld EP, Callans DJ, Marchlinski FE. Clini- 41. See VY, Roberts-Thomson KC, Stevenson WG, Camp PC, Koplan BA. cal predictors and outcomes associated with acute return of pulmonary vein con- Atrial arrhythmias after lung transplantation: epidemiology, mechanisms at duction during pulmonary vein isolation for treatment of atrial fibrillation. Heart electrophysiology study, and outcomes. Circ Arrhythm Electrophysiol 2009;2: Rhythm 2006;3:1024–1028. 504–510. doi:10.1093/eurheartj/ehq269 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 30 July 2010 ............................................................................................................................................................................. Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial embolism: the ‘Pitcher Syndrome’ 1 2 1 Daniela Reutter , Roger Hunziker , and Marc Husmann * 1 2 Clinic for Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; and Department of Radiology, University Hospital Zurich, Zurich, Switzerland * Corresponding author. Tel: +41 44 255 3491/+41 44 255 2650, Fax: +41 44 255 4510, Email: marc.husmann@usz.ch Embolic brachial artery occlusion most often originates from the heart, the aortic arch, or from subclavian artery aneurysms. A 64-year-old man presented with acute upper limb ischaemia of the left arm. Duplex sonography confirmed a brachial artery occlusion, but no com- pression of the left subclavian artery or a subclavian aneurysm as source for the emboli. There were no signs for cardiac arrhythmia in the ECG nor cardiac thrombus by echocardio- graphy. Computed angiogram of the thoracic and upper extremity revealed an aneurysm of the left posterior circumflex humeral artery (Panels A and B). Treatment con- sists in surgical embolectomy at the brachial bifurcation and in ligation of the aneurysm. Aneurysms of the posterior circumflex humeral artery have been reported for volleyball and baseball players and named as the ‘Pitcher Syndrome’. Repetitive traumas to the arterial wall during throwing motions of the shoulder affect the posterior circumflex humeral artery at the quadrangular space at the neck of the humerus. Embolic occlusion may result from dislocation of the squeezed thrombus from the aneurysmatic sack during shoulder movements. Since this patient did never practice any other sports than yoga, it might be assumed that certain specific yoga exercises with shoulder movements might have provoked the artery trauma. The absence of cardiovascular source for thrombo-embolism by echocardiography, ECG, and vascular sonography demands additional vascular imaging that allows an entire vascular assessment to detect rare sources for embolism. Panel A. Three-dimensional volume rendering computed tomography image. Aneurysm of the left posterior circumflex humeral artery (white arrow) and thromboembolic occlusion of the left brachial artery bifurcation (white arrowhead). Panel B. Transverse computed tomography image. Aneurysm of the left posterior circumflex humeral artery (white arrow). Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org.

Journal

European Heart JournalOxford University Press

Published: Nov 30, 2010

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