Acute-on-Chronic Upper Limb Ischemia Precipitated by Critical Right Brachiocephalic Stenosis

Brachiocephalic artery stenosis is an uncommon cause of upper extremity ischemia and cerebrovascular insufficiency. Diagnosis may be delayed because of subtle clinical manifestations, particularly in patients with established atherosclerotic risk factors.

A 73-year-old woman with diabetes, dyslipidemia, and active tobacco use presented with progressive bluish discoloration and pain of the right-hand digits. The primary care physician initially misattributed the presentation to Buerger disease. Angiography revealed critical ostial brachiocephalic artery stenosis, and prompt endovascular stenting showed improvement in digital perfusion and eventual resolution of symptoms.

This case highlights the potential for isolated upper extremity digital ischemia to represent proximal great vessel disease, especially among high-risk smokers. Careful examination and imaging are important for avoiding a missed diagnosis. Smoking cessation remains essential for long-term protection.

Detailed examination and interarm blood pressure measurement should be routinely performed in patients with unexplained upper-extremity ischemia to identify potential proximal great-vessel disease.