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Kinked Brachial Artery: A Technical Issue Masquerading As Steal Syndrome
Benjamin Feng, BS, Maleek Masood, MD, Ann Yufa, MD, Nadia Awad, MD.
Einstein Medical Center, Philadelphia, PA, USA.
Demographics: The patient is a 77-year-old female with a significant medical history, including end-stage renal disease (on hemodialysis), hypertension, hyperlipidemia, left breast cancer, lymphedema, type 2 diabetes mellitus, hepatitis C, and lumbar spine fixation. She is also an active smoker.
History: The patient presented with symptoms of steal syndrome, including weakness, and radiating pain down the arm, following the placement of a left upper extremity loop arteriovenous (AV) graft at an outside hospital. The loop graft subsequently thrombosed but the patient had persistent symptoms. Angiography revealed a near-occlusive stenosis of the left brachial artery at the AV graft anastomosis due to a sharply kinked left brachial artery. Preoperative examination revealed weak monophasic signals distal to the site.
Plan: The patient was taken to the operating room for a left brachial artery bypass to address the arterial kinking and stenosis. The dissection was complicated by significant scar tissue and inflammation surrounding the brachial vessels, requiring meticulous dissection to isolate the artery. The severely diseased and kinked segment of the brachial artery was resected, and an interposition 6mm PTFE graft was placed. The bilateral great saphenous veins were less than 2mm and contralateral arm vein was being saved for future dialysis access. Post-procedure, the patient had palpable radial and ulnar pulses and improvement of pain and weakness in the distal extremity.
Discussion: This case report highlights an unusual presentation of complications of dialysis access. In this patient, sharp kinking of the brachial artery secondary to the AV graft led to severely impeded blood flow to the arm and hand, initially causing symptoms consistent with steal syndrome—namely, pain, weakness, and ischemia. However, these symptoms persisted even after occlusion of the access. This case emphasizes the need to consider mechanical factors, such as arterial kinking, as a cause of steal syndrome-like symptoms.
Fig. 1. Pre-intervention anatomy (left) showing a kinked brachial artery (vessel loops) by the AV graft (star), and post-intervention anatomy (right) demonstrating a successful PTFE graft bypass of the brachial artery.
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