Hunziker, Roger

Husmann, Marc

Reutter, Daniela

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32. Jalife J, Berenfeld O, Skanes A, Mandapati R. Mechanisms of atrial fibrillation:mother rotors or multiple daughter wavelets, or both? J Cardiovasc Electrophysiol1998;9:S2–S12.33. Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T,Khunnawat C, Ngarmukos T. A new approach for catheter ablation of atrial fibril-lation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004;43:2044–2053.34. Schauerte P, Scherlag BJ, Patterson E, Scherlag MA, Matsudaria K, Nakagawa H,Lazzara R, Jackman WM. Focal atrial fibrillation: experimental evidence for apathophysiologic role of the autonomic nervous system. J Cardiovasc Electrophysiol2001;12:592–599.35. Roberts-Thomson KC, Stevenson IH, Kistler PM, Haqqani HM, Goldblatt JC,Sanders P, Kalman JM. Anatomically determined functional conduction delay inthe posterior left atrium relationship to structural heart disease. J Am CollCardiol 2008;51:856–862.36. 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J Am Coll Cardiol 2008;51:793–801.40. Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC,Pettersson GB, Blackstone EH. Atrial fibrillation after lung transplantation: timing,risk factors, and treatment. Ann Thorac Surg 2007;84:1878–1884.41. See VY, Roberts-Thomson KC, Stevenson WG, Camp PC, Koplan BA.Atrial arrhythmias after lung transplantation: epidemiology, mechanisms atelectrophysiology study, and outcomes. Circ Arrhythm Electrophysiol 2009;2:504–510.CARDIOVASCULAR FLASHLIGHT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehq269Online publish-ahead-of-print 30 July 2010Computed angiogram of the upper extremities for diagnosing a rare causeof brachial arterial embolism: the ‘Pitcher Syndrome’Daniela Reutter1, Roger Hunziker2, and Marc Husmann1*1Clinic for Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; and 2Department 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.chEmbolic brachial artery occlusion mostoften originates from the heart, theaortic arch, or from subclavian arteryaneurysms.A 64-year-old man presented withacute upper limb ischaemia of the leftarm. Duplex sonography confirmed abrachial artery occlusion, but no com-pression of the left subclavian arteryor a subclavian aneurysm as sourcefor the emboli. There were no signsfor cardiac arrhythmia in the ECGnor cardiac thrombus by echocardio-graphy. Computed angiogram of thethoracic 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 circumflexhumeral artery at the quadrangular space at the neck of the humerus. Embolic occlusion may result from dislocation of the squeezedthrombus from the aneurysmatic sack during shoulder movements. Since this patient did never practice any other sports than yoga, itmight 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 demandsadditional 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 humeralartery (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.G. Lee et al.2782

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

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