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(Circulation. 2008;117:2542-2543.)
© 2008 American Heart Association, Inc.

Images in Cardiovascular Medicine

"String of Beads" Appearance of Bilateral Brachial Artery in Fibromuscular Dysplasia

Tsuyoshi Yoshimuta, MD; Koichi Akutsu, MD; Toshiya Okajima, MD; Yuiichi Tamori, MD; Yoshinori Kubota, BS; Satoshi Takeshita, MD

From the Department of Medicine (Cardiology) (T.Y., K.A., T.O., Y.T., S.T.) and the Laboratory of Clinical Physiology (Y.K.), National Cardiovascular Center, Osaka, Japan.

Correspondence to Satoshi Takeshita, MD, FACC, Department of Medicine (Cardiology), National Cardiovascular Center, 5–7–1 Fujishiro-dai, Suita, Osaka 565–8565, Japan. E-mail stake{at}muse.ocn.ne.jp

A 56-year-old woman presented with chest discomfort and underwent coronary angiography via a transradial route. Left brachial artery stenosis was suspected because of difficulty in passing with a 0.035-inch guide wire. Upper-extremity angiography showed presence of multiple stenoses and aneurysmal dilatations in her brachial artery (Figure 1). Subsequent to catheterization, the patient received duplex scanning using Aplio SSA-700A (Toshiba, Tokyo, Japan) using the advanced dynamic flow mode. This mode is associated with high resolution, wide dynamic range, and high frame rates and is capable of producing a superior angiograph-like vascular image. Duplex scanning showed serial stenoses alternating with aneurysmal dilatations over a length of approximately 10 cm in her bilateral brachial arteries, which is a typical "string of beads" appearance of fibromuscular dysplasia (FMD)¹ (Figure 2).

View larger version (101K): [in this window] [in a new window]   Figure 1. Upper-extremity angiogram showing multiple stenoses and aneurysmal dilatations in the brachial artery.

View larger version (25K): [in this window] [in a new window]   Figure 2. B-mode (left) and advanced dynamic flow mode (right) images demonstrating segmental stenoses and dilatations of the brachial artery, which shows the typical "string of beads" appearance of fibromuscular dysplasia.

FMD usually affects the renal and carotid arteries, and brachial artery involvement is very rare. To our knowledge, there have been only 4 cases of FMD involving bilateral brachial arteries reported thus far in the literature.² Pathologically, 3 main types of FMD have been identified, which include intimal fibroplasia, medial FMD, and periarterial fibroplasia.³ Among these, medial FMD is the most common, accounting for 70% to 95% of all fibromuscular vascular lesions.¹ As shown in Figure 2, arterial narrowing within the "string of beads" segment is caused by protrusion of the dysplastic arterial media, whereas aneurysmal dilatation results from deficit of the arterial media. Although FMD is a histological diagnosis, its diagnosis is usually made by angiography with a high degree of accuracy on the basis of the "string of beads" appearance. Ultrasound examination with advanced dynamic flow mode produces superior angiograph-like images and appears to be useful for noninvasive diagnosis of FMD.

	Disclosures

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None.

	References

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1. Lüscher TF, Lie JT, Stanson AW, Houser OW, Hollier LH, Sheps SG. Arterial fibromuscular dysplasia. Mayo Clin Proc. 1987; 62: 931–952.[Medline] [Order article via Infotrieve]

2. Kolluri R, Ansel G. Fibromuscular dysplasia of bilateral brachial arteries: a case report and literature review. Angiology. 2004; 55: 685–689.[CrossRef][Medline] [Order article via Infotrieve]

3. Harrison EG Jr, McCormack LJ. Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clin Proc. 1971; 46: 161–167.[Medline] [Order article via Infotrieve]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yoshimuta, T. Articles by Takeshita, S. Search for Related Content PubMed PubMed Citation Articles by Yoshimuta, T. Articles by Takeshita, S. Related Collections Cardiovascular imaging agents/Techniques Peripheral vascular disease Doppler ultrasound, Transcranial Doppler etc.