Subclavian Angioplasty in a Renal Transplant Patient

A 41 year old white male with a renal transplant was admitted to St. Francis Hospital with discoloration and pain of the left thumb and index finger. He had a medical history of insulin dependent diabetes mellitus for 24 years, renal transplant two years ago, a left below knee amputation five months ago, diabetic retinopathy, diabetic neuropathy and hypertension. He had noted some bluish discoloration in the fingertips of his left thumb and index finger, one week prior to the admission. The discoloration progressed gradually, with associated pain, especially worsened by walking with crutches. On the day of the admission, he awoke from a nap with severe shoulder pain, prompting him to seek medical attention. He was currently on Azathiprine, Prednisone, Furosemid, Clonidine, and insulin. On physical examination, the distal phalanges of the left thumb and index finger were cyanotic. The entire arm was cool upon palpation, with absent pulses in the left brachial, radial and ulnar arteries. The laboratory revealed a hematocrit of