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Difficulty: HardCardiothoracic and Vascular Surgery

Match each patient's clinical presentation to the most likely underlying vascular or thoracic pathology.

  • A 55-year-old man experiences vertigo and left arm fatigue during manual labor; examination reveals a 30 mm Hg systolic blood pressure differential between his arms.Stenosis or occlusion of the proximal subclavian artery
  • A 60-year-old man with a 40-pack-year smoking history presents with new-onset erectile dysfunction, bilateral gluteal claudication, and globally diminished lower extremity pulses.Severe atherosclerotic occlusion of the terminal aorta and common iliac arteries
  • A 25-year-old competitive swimmer presents with acute right upper extremity edema, cyanosis, and a heavy sensation in the arm without prominent sensory deficits.Thrombosis of the axillary-subclavian vein secondary to repetitive trauma
  • A 32-year-old woman complains of progressive right hand intrinsic muscle atrophy and paresthesias along the medial aspect of the forearm that worsen when lifting her arms above her head.Compression of the lower trunk of the brachial plexus (C8-T1)

Answer

Presentation 1 matches proximal subclavian artery stenosis; Presentation 2 matches terminal aorta occlusion; Presentation 3 matches axillary-subclavian vein thrombosis; Presentation 4 matches brachial plexus compression.
Each patient presentation contains hallmark findings that uniquely correlate to a specific anatomical defect. The pairing requires differentiating between arterial insufficiency (Leriche, Subclavian Steal), venous outflow obstruction (Paget-Schroetter), and peripheral nerve compression (Neurogenic TOS).

Step-by-Step Solution

1
Analyze the first presentation (vertigo, arm fatigue, BP differential).
Identified as Subclavian Steal Syndrome.
The BP differential indicates an anatomical arterial stenosis, and the exertion-induced vertigo confirms retrograde vertebral flow.
2
Analyze the second presentation (ED, gluteal claudication, absent pulses).
Identified as Leriche Syndrome.
These three symptoms perfectly match the classic triad of aortoiliac occlusive disease.
3
Analyze the third presentation (swimmer with acute arm edema and cyanosis).
Identified as venous thoracic outlet syndrome (Paget-Schroetter disease).
The sudden swelling and blue discoloration in an athlete using repetitive overhead arm motions indicates venous outflow obstruction (thrombosis).
4
Analyze the fourth presentation (hand atrophy, medial forearm paresthesias, overhead exacerbation).
Identified as neurogenic thoracic outlet syndrome.
The ulnar nerve distribution symptoms (C8-T1) exacerbated by overhead movement isolate the pathology to the lower trunk of the brachial plexus.

Key Concept

Clinical diagnosis of vascular and thoracic outlet syndromes based on precise physical examination and historical findings.
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Topics

Cardiothoracic and Vascular Surgery

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