Author + information
- Received April 10, 2017
- Revision received May 8, 2017
- Accepted May 23, 2017
- Published online September 4, 2017.
- Yoshito Kadoya, MD∗ (, )
- Kan Zen, MD, PhD and
- Satoaki Matoba, MD, PhD
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- ↵∗Address for correspondence:
Dr. Yoshito Kadoya, Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
An 80-year-old woman diagnosed as having severe aortic stenosis underwent pre-operative coronary angiography through the left radial artery for transcatheter aortic valve implantation. A 0.025-inch guidewire was advanced into the left brachial artery for sheath insertion. Upper extremity angiography was performed because it was difficult to pass the wire through the artery; the angiogram showed alternating stenoses and dilatations (i.e., a “string of beads appearance”) in the left brachial artery (Figure 1A). The optical coherence tomography scan showed thickening of the middle layer (Figure 1B, Online Video 1), causing intraluminal protrusion of the arterial segment (Figure 1C). Angioscopy demonstrated intraluminal fibrous webs (arrows) as white, wall-like structures protruding into the lumen and contacting the wire (arrowheads); no thrombus was observed (Figures 1D and 1E, Online Video 2). Therefore, the diagnosis was brachial artery fibromuscular dysplasia (FMD). Because the patient was asymptomatic and no pressure gradient was observed across the FMD segment, no interventions or additional medical treatment was performed. Subsequently, the sheath was successfully passed through the narrowing segment, and transradial coronary angiography was completed. Further investigation showed no FMD lesions in other arterial territories.
FMD is a nonatherosclerotic, noninflammatory angiopathy that causes narrowing of medium-sized arteries, and it is characterized by fibrodysplastic changes (1). Although catheter-based angiography is the gold standard for diagnosing FMD, it may be inadequate for visualizing intraluminal fibrous webs, whereas optical coherence tomography and angioscopic imaging can clearly show the presence of webs in the brachial artery. In the era of transradial catheter intervention, the importance of diagnosing brachial artery FMD should be recognized.
For supplemental videos and their legends, please see the online version of this article.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 10, 2017.
- Revision received May 8, 2017.
- Accepted May 23, 2017.
- 2017 American College of Cardiology Foundation