Blood letting as an ancient cure for an unusual manifestation of polycythemia

A 52-year-old woman presented with acute digital ischemia and pain in all five digits of her right hand. Upper extremity arterial duplex demonstrated normal flow to the wrist, but upper extremity Computed Tomography Angiography (CTA) demonstrated an atretic appearing brachial artery at the mid-humerus, variant superficial ulnar artery, and a radial artery that truncated at the wrist. The patient was diagnosed with digital ischemia secondary to polycythemia and was started on intravenous anticoagulation. Her symptoms improved and she was converted to oral anti-coagulation and anti-platelet therapy supplemented by weekly therapeutic phlebotomy. The patient's condition improved at 1-month follow up, as indicated by laboratory, imaging, and symptoms. In this case report, we detail the presentation and management of upper extremity ischemia in the setting of polycythemia in a patient with small, tortuous, and aberrant vasculature.