arterial arm partial occlusion?

[sk8flo]

At Rheumotolgists appt in early Jan 2011, tech could not obtain BP in left arm, 120/80 in right arm.  Nothing more said.  Over the weeks, I had great difficulty finding weak radial and brachial pulse.  Started having some tingling in finger tips and ache posterior upper arm.  Color remains good, occ blanching in hand.  Past 3 mornings I took bilateral BP (NIBP cuff) at work with ff. measurements.  L 79/58, R 119/66; L77/51, R 119/56; L 83/55, R121/58.  I'm on plaquenil for MCTD and Symbicort for COPD/emphysema.  Echo and persantine test 10.2010 basically ok.  One year ago had 3 drop attacks in a week and witnessed brief (?) TIA.  All MRI/MRA head and neck studies at that time were normal; tortuous left vertebral artery.  MD felt I had kinked VA with head position and strain.  I already have C3-6 fused and significant OA at C1-2.  Am 64, 5'3" 114 lbs.  I also have been on and off prednisone as needed for hand (wrist/knuckle joint pains and swelling both hands left greater than right,)

Am not sure how to best pursue this, if indeed it needs any further evaluation.  Comment?  What would be initial work-up studies?

[Lee Kirksey, MD]

Hello
A number of studies are available. the noninvasive options would be pulse volume recording and ultrasound which would determine the objective differential pressure at various levels and reveal the level of occlusion. Next step would be CTA or angiography. Its important to determine if you have clots or occlusion and where it came from as this could occur elsewhere
Best of luck

[sk8flo]

I saw a vascular surgeon today who did doppler color ultrasound.....yes, left vertebral artery is very tortuous, blood flow going both directions and said I have subclavian steal syndrome.  He also was able to look on Synapse my 1-1/2 yr old films MRA/MRi  from when I had drop attacks and TIA (looked okay) and my CT Angio done last week and that showed the stenosis.   He found site of left subclavian artery stenosis further out (distally) than the normal stenotic sites.  
Since I am already taking ASA, nothing more to do at this time unless I become symptomatic with arm fatigue, claudication, etc.  Then a balloon procedure might be indicated.  Just have to remind people to take BP only in the right arm, not the left, and for me to do my own monitoring as for now right systolic does fluctuate between 120-160.  No antihypertensives would be needed unless I sustain high readings.

Thank you again for your interest and comments.   They were greatly appreciated.  And yes, PCP did take me seriously especially after she took BP L 90 systolic, R 156 systolic and requested I see vascular surgeon.

[Lee Kirksey, MD]

There are a number of causes of extremity occlusion in the axillary, subclavian or brachial artery. You should be referred to a vascular specialist, in this case vascular surgeon, to own the problem, take you serious and determine appropriate management

Best of health

[sk8flo]

Thank you for your reply - so I assume you do advocate a follow-up.  I am seeing my PCP tomorrow for follow-up due to viral respiratory infection that started 2/1.  That past few days I have notice black streaks under the distal nailbed - ? vasculitis..

My other concern was on 2/21 when I returned to work after illness, L 83/63 R 146/69  BP stayed elevated 2 days (L97/60 R 159/88) and then came back down today L86/52,  R 124/60.  The only connection I could make was a sinus arrythmia  (HR 85-95) at time of increased Rt. BP.

I hope my PCP will take this seriously.  I have read that a difference is not unusual but the range given is listed as less than 30.   Thank you again for your imput.