Subclavian steal syndrome is an uncommon entity diagnosed with angiography after neurologic symptoms occur during activity with the upper extremity. Cardiac symptoms or silent ischemia have been described in patients who have undergone cardiac bypass using the ipsilateral internal mammary artery. Our patient presented with acute chest pain radiating to the left upper extremity and a diminished pulse. Angiography to rule out an acute embolus instead revealed subclavian artery occlusion. As atherosclerosis is the most common cause, the ipsilateral subclavian artery should be carefully evaluated, particularly in cardiac patients undergoing coronary angiography. Recognition of coexisting subclavian artery occlusion could prevent cardiac complications that may occur with use of the ipsilateral internal mammary artery during coronary artery bypass surgery.

No abstract

The differential for liver transaminases over 1000 units/liter typically includes liver ischemia, acute viral hepatitis, acetaminophen toxicity, and autoimmune hepatitis. Prompt evaluation is imperative as these etiologies can lead to fulminant liver failure. We present a case of transaminases over 1000 units/liter from an atypical etiology. A 52-year-old male, previously treated with allopurinol for an acute gout flare, presented with persistent fevers. Given that he had taken a “high-risk medication” 2–6 weeks before presentation, subsequently presented with fever, rash, renal impairment, elevated liver enzymes in the thousands, and peripheral eosinophilia, DRESS syndrome secondary to allopurinol was diagnosed.

Aortic graft infection is one of the most dreaded surgical complications. In the perioperative patient with fresh aortic prosthesis, this is a particularly complex problem. Opening the bowel changes an operation to a "clean-contaminated" or "contaminated" case. This increases the risk of all infectious complications in the patient. Theoretically, our method of repair reduces the risk of infection by eliminating the duodenotomy. The direct visualization with the endoscope replaces the need to open the potentially contaminated bowel and reduces the risk of bacterial translocation and bacteremia. By not opening the bowel, this keeps the case "clean," and likely reduces the risk of contamination and subsequent infection of the prosthetic graft. As the potential morbidity of aortic graft infection is so devastating, and now that we have the available technology and operative skill, we propose our technique as a potential alternative to possibly reduce the incidence of aortic graft infection.