RT Journal Article
SR Electronic
T1 Wrist mass in a 93-year-old woman
JF Heart
JO Heart
FD BMJ Publishing Group Ltd and British Cardiovascular Society
SP heartjnl-2017-311923
DO 10.1136/heartjnl-2017-311923
A1 Annette Marie Maznyczka
A1 Domenico Valenti
A1 Jonathan Byrne
YR 2017
UL http://heart.bmj.com/content/early/2017/10/09/heartjnl-2017-311923.abstract
AB Clinical introduction A 93-year-old woman presented electively for transaortic valve implantation (TAVI), for severe aortic stenosis. She had a history of hypertension and hypothyroidism, and she was taking clopidogrel, antihypertensives and levothyroxine. In preparation for her TAVI procedure she underwent coronary angiography 4 months previously. Her coronary angiogram revealed severe three vessel disease, however, the consensus from the multidisciplinary team meeting, at that time, was to manage the coronary disease medically. Physical examination revealed a large, non-tender swelling on the volar aspect of her wrist (figure 1). The swelling had progressively enlarged in size over the preceding 4 months. Duplex ultrasonography was performed, but was technically difficult. Turbulent bidirectional flow was seen within the wrist swelling, however the connecting tract from which the flow originated was not adequately visualised. The greyscale ultrasound is shown (figure 1).Figure 1 The panel on the left shows the swelling on the volar aspect of the wrist. The panel on the right shows the grey scale ultrasound image of the swelling at the wrist.Question  What is the next most appropriate management step?Antibiotics and drainageUrgent ultrasound guided thrombin injectionNon-emergent vascular surgeryConservative management, with observation and follow-upUltrasound guided compressionQuestion