Upper limb artery segmental occlusions due to chronic use of ergotamine combined with itraconazole, treated by thrombolysis

Brachial Artery Vasospasm From Sequential Use of Intravenous Promethazine and Dihydroergotamine for Treatment of Status Migrainosus: A Case Report

Promethazine, a common antiemetic, can cause severe tissue injury with intravenous (IV) injection. Dihydroergotamine (DHE), commonly used for the acute treatment of migraine, can cause arterial vasoconstriction. We report a rare complication of brachial artery vasospasm in a patient receiving IV promethazine and DHE sequentially through the same midline IV catheter. A 40-year-old woman with history of migraine headaches and Raynaud phenomenon was admitted for treatment of status migrainosus with scheduled IV DHE infusions. While receiving the DHE infusions, IV promethazine was added to the patient’s regimen to treat nausea. During an infusion of DHE, the patient developed acute pain near the catheter insertion site due to active extravasation of IV DHE. An arterial Doppler ultrasound demonstrated stenosis in the right brachial artery near the region of infusion. The patient ultimately required balloon angioplasty and intra-arterial injection of nitroglycerin to restore adequate blood flow. We hypothesize that caustic injury to the right brachial vein from IV promethazine predisposed the patient to the extravasation of DHE, which, in turn, caused adjacent brachial artery vasospasm. This case suggests the need for careful consideration, if not strict avoidance, of the use of concurrent IV promethazine and DHE.

Critical upper limb ischemia caused by initially undiagnosed thoracic outlet syndrome--case report

A case of a progressive ischemia of the right upper extremity in a 57-year-old male caused by primarily undiagnosed compression of a subclavian artery by an accessory cervical rib is presented. Critical limb ischemia persisting for 7 years despite conservative treatment and a thrombectomy of upper extremity arteries and thoracic sympathectomy, led to a loss of three fingers and development of a non-healing ulceration of right upper extremity. Eventually a cervical rib resection together with a subclavio-brachial venous bypass graft permanently reversed the critical limb ischemia and allowed the ulceration to heal. The presented case underscores the importance of an early surgical intervention in patients with upper limb ischemia and anatomic abnormalities in a thoracic outlet.