SHM Converge Scientific Abstract ePoster Gallery-Pseudohypotension in the Setting of Subclavian Artery Stenosis

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This case report describes pseudohypotension caused by severe peripheral vascular disease and subclavian artery stenosis. A 66-year-old woman with ESRD on hemodialysis, heart failure, and advanced atherosclerosis was repeatedly treated for presumed hypotension and sepsis after placement of a right arm AV graft. Over several hospitalizations, she received ICU care, vasopressors, and then high-dose midodrine, while her heart failure guideline-directed medical therapy (GDMT) was stopped. She also developed recurrent flash pulmonary edema and was considered a poor surgical candidate for an abdominal mass because of the apparent low blood pressure.<br /><br />During a later admission, clinicians carefully reviewed imaging and discovered severe three-territory peripheral vascular disease, including chronic left subclavian artery stenosis and severe aortic and iliac atherosclerosis. When blood pressure was measured in different limbs, the right arm read 200/100 mmHg while the left arm read 80/40 mmHg, revealing that prior “hypotension” had been falsely low in the affected limb. The right arm pressures were elevated because the AV graft was placed there, and the left arm pressures were artifactually low because of proximal subclavian disease. The patient had no signs of true shock: she remained mentally intact, had normal lactate, and lacked end-organ injury, which helped confirm the diagnosis.<br /><br />After stopping midodrine and restarting GDMT, she underwent aggressive dialysis with more than 10 kg of fluid removed and had no further admissions aside from successful removal of the abdominal mass.<br /><br />The report emphasizes that pseudohypotension can result in misdiagnosis, unnecessary vasopressors, inappropriate stopping of beneficial therapies, and worsening hypertension or heart failure. In patients with severe vascular disease and apparent hypotension without end-organ dysfunction, clinicians should confirm blood pressure in multiple limbs and consider subclavian stenosis or other vascular obstruction.

Asset Subtitle

Ali Ismail

Meta Tag

Author List Ali Ismail, Jeremy Santamaria

Category Clinical Vignettes

Concept Pseudohypotension

Concept Peripheral Arterial Disease

Concept Subclavian Artery Stenosis

Concept Blood Pressure Measurement

Concept Inter-Arm Blood Pressure Difference

Distinguished Non-Finalist

Presenter Organization CorewellHealth

Presenting Author Ali Ismail

Track Adult

Keywords

pseudohypotension

subclavian artery stenosis

peripheral vascular disease

end-stage renal disease

hemodialysis

arteriovenous graft

heart failure

vasopressors

midodrine

blood pressure measurement

Pseudohypotension

Peripheral Arterial Disease

Subclavian Artery Stenosis

Blood Pressure Measurement

Inter-Arm Blood Pressure Difference