Subclavian and axillary arterial injuries are uncommon and in the setting of scapulothoracic dissociation present difficulties in diagnosis, assessment, and reconstruction. We present a case of subclavian artery disruption in such a setting, in which palmar duplex identified the need for reperfusion and provided assessment of an extra-anatomic bypass. Palmar arterial duplex may provide a useful tool in select cases of upper extremity arterial trauma.

Shock represents a state when arterial perfusion is inadequate to supply the needs of cellular respiration, leading to anerobic metabolism, acidosis, and cell death. Although typically described in terms of blood pressure and heart rate, these measures can both lead to delayed recognition of shock and under appreciation of the severity of end-organ malperfusion. Recently, there has been increased interest in monitoring peripheral perfusion both to detect early shock and monitor the response to treatment. However, current methods are variable and, in some cases, require specialized equipment. We present a case in which duplex ultrasound assessment of peripheral palmar acceleration time identified a post-hemorrhagic shock state before it was clinically apparent. Bedside arterial duplex and hand acceleration time may provide a simple tool to assess the degree of shock and response to intervention.

A pilot study assessing the efficacy of a nonsupervised exercise program for intermittent claudication is described, and case descriptions of 4 patients are presented. The ankle/brachial index (ABI) has long been the standard for evaluating lower limb perfusion; however, the ABI is not reliable with noncompressible arteries. Pedal acceleration time (PAT), a novel technique that quantifies perfusion using duplex ultrasound by measuring the acceleration time of the arterial waveform, has been found to be more reliable. When considering only ABI, nonsupervised exercise is not sufficient management of claudication in peripheral arterial disease (PAD), but PAT may be more sensitive to changes in collateral blood flow developed by exercise. We initiated a pre-post study from a single institution over 6 weeks that included a walking program for patients with claudication with modified resistance band exercises for amputees. Changes in symptoms, smoking, and the perfusion markers of resting ABI and anterior pedal and posterior pedal PAT were monitored. Of the 4 patients described, 3 noted symptomatic improvement with categorical improvement in PAT. Compliant patients do report success with at-home exercise regimens. Patients who are unsuccessful may benefit from supervised vascular rehabilitation. PAT, in comparison with ABI, may offer a better approach to monitor this progression and offer a stepwise approach to the management of PAD.