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Acute occlusive disease of upper limb

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1 Acute occlusive disease of upper limb
Princess Margaret Hospital Law Hang Sze

2 Upper limb ischaemia <5% all extremity ischaemia
Small vessel disease involving palmar and digital arteries – majority <10% of upper-extremity arterial occulsive disease at large vessel Atherosclerosis is rare (vs LL) Differences in pattern of diseases

3 Proximal Large artery Sources of Embolism to Distal Small Arteries
Arterial Vasospasm Ergotism Idiopathic vasospastic Raynaud’s syndrome Vinyl choloride exposure Arterial Obstruction Large artery causes Atherosclerosis Thoracic outlet syndrome Arteritis (Takayasu’s, Giant cell) Fibromuscular disease Small artery causes Connective tissue disease Scleroderma, RA, Sjogren syn, SLE Myeloproliferative disease Thrombocytosis Leukaemia Buerger’s disease Cytotoxic drugs Hypercoagulable state Arterial drug injection Proximal Large artery Sources of Embolism to Distal Small Arteries Ulcerated or stenotic atherosclerotic plaques Aortic arch Innominate artery Subclavian artery Aneurysms Axillary or brachial artery Ulnar artery

4 Case illustration 25-year-old male professional basketball player
Good past health non-smoker Left upper limb pain for few days, numbness and coldness No History of direct trauma

5 History Complete and thorough past medical history
risk factors e.g. cardiovascular, atherosclerotic disease, renal failure symptoms suggesting of connective tissue diseases Symptoms of claudication Swallowing -> scleroderma arthritic-type of symptoms rashes or other cutaneous lesions e.g. SLE, coagulopathy

6 history of unusual bleeding or clotting associated with other surgical procedures
Family history History of previous trauma, environmental exposure, work-related and lifestyle-related source of trauma Iatrogenic injury: previous cardiac catheterization Medication history: beta-blockers, intra-arterial injection Sports history: baseball, basketball, weight-lifting

7 Physical examination Inspection of finger nail
Palpation of axillary, brachial, radial, ulnar pulses Allen test/ Adson’s test Finger cyanosis or discoloration or tenderness Ulceration or frank gangrene Previous punctures or incisions (arterial line, previous AV access)

8 Decreased sensory function, paresthesias, dysesthesias
Thoracic outlet, median nerve at wrist, ulnar nerve at elbow Unilateral (embolic source) or bilateral (systemic origin e.g. scleroderma) Palpable mass - aneurysm

9 Case Left hand finger tips cyanotic
Left brachial, ulnar and radial pulses weak compared to right side Capillary refill ~3sec No ulcer No palpable mass or soft tissue swelling over left upper limb Neurological examination unremarkable

10 Management History and physical examination
Vs more predictable causes of lower-extremity disease Duration, nature of symptoms Speed of onset (embolic or microembolic events) Raynaud symptoms (long history, course of symptoms, exacerbating factors)

11 Treatment flow plan for acute upper limb ischaemia
Hx, medical, occupational/sport, drug, P/E, Doppler Radial and ulnar pulse -ve OT Angiogram/CT angiogram Acute on chronic causes/ proximal lesion OT +/- medical treatment Radial and ulnar pulse +ve Small arterial lesions Workup + medical treatments

12 Treatment Acute embolism
Level of occlusion: clinical and non-invasive investigations In cases of obvious cardiac source of embolism  immediate embolectomy +/- Angiography/ CT angiogram: to locate proximal embolic source and differentiate thromboembolism from acute thrombosis Heparin infusion to prevent propagation

13 Treatment Embolectomy via transverse arteriotomy at antecubital fossa
For intra-operative angiography if adequate inflow not achieved or radial or ulnar pulse not restored Secondary radial, ulnar and axillary embolectomy

14 Treatment Acute thrombosis
Level of occlusion by physical examination and non-invasive investigation +/- Angiography/ CT angiogram Thrombolysis Exploration with thrombectomy

15 Treatment Acute on chronic causes
Embolectomy or thrombolysis, thrombectomy for acute event Angiography/ CT angiogram Treat underlying causes, e.g. aneurysms, arteritis, thoacic outlet syndrome etc Medical treatment Bypass, endovascular surgery, transposition Prevention/ Long term control

16 M/25 Bedside Doppler USG: absence of pulsation at left radial and ulnar arteries CT angiogram: long segment of complete arterial occlusion at left proximal brachial artery. A 1.5x1.3cm aneurysm with thrombus inside arising from distal left axillary artery with wide neck.




20 Treatment Exploration under GA Left axilla incision
Aneurysm found arising from branch of left axillary artery. Size of aneurysm 3cm. Wide neck communicating with left axillary artery Excision done, neck closed with 5O Gortex

21 Subsequently transverse arteriotomy at left brahcial artery
Embolectomy with Forgarty catheter On-table angiogram showed contrast reaching wrist level Post op Doppler USG confirmed arterial blood flow resumed at left radial and ulnar arteries

22 Heparinised and warfarinised
Symptoms improved Left ulnar and radial pulses +ve Capillary refill <2sec No evidence of reperfusion injury No evidence of compartment syndrome

23 Further investigation
Holter ECG showed no arrhythmia Echocardiogram was normal Other blood tests unremarkable Fully regain daily activity

24 Follow up CT angiogram:

25 Acute ischaemia Presentation: severe pain, pallor, pulselessness, paraesthesia, paralysis collaterals maybe inadequate means devastating outcome if not revascularise in time emboli – from heart or large proximal vessel Thrombosis Trauma - penetrating, blunt or iatrogenic, fracture, dislocation of shoulder, use of clutches

26 Emboli tend to lodge at bifurcation 1/2 impacted in brachial artery
1/3 impacted in axillary artery Rarely ulnar and radial arteries 65-80% arise from thrombus in the heart 2/3 related to AF, 1/3 due to mural thrombus in MI Others due to proximal arteries atherosclerotic plaques, aneurysm, site of surgery, tumour and trauma Arterial emboli to the arm Journal of the Royal College of surgeons of Edinburgh 1991; 36: 83-5 Vohra R, Lieberman DP Both main arterial channel and collateral input

27 investigations Laboratory tests for connective tissue disease and coagulation e.g. RF, ANA, C3, C4, PT, partial thromboplastin time, protein C, protein S ECG CXR Vascular laboratory studies: Plethysmography segmental pressures digital pulse volume recordings (PVRs) to reactive hyperemia duplex USG

28 Duplex and color doppler USG
Non invasive Precise anatomical information Location of stenotic or occlusive disease Extent and severity collaterals Define patency of distal arteries AVM, aneurysm Disadvantage: subclavian artery

29 angiography In cases with significant tissue loss
Suspicious of a more proximal source of occlusive disease Claudication For definitive diagnosis and for pre-op planning Visualize entire upper limb from subclavian artery to digital tuft arteries Risks of vasospasm in vasospastic disease

30 CT angiogram Identify bony structures and relation to vessels
Aneursyms of subclavian and brachial vessels aortic dissection Non-invasive 3D reconstruction available

31 6 due to atherosclerosis (10.5%) 9 due to trauma (15.8%)
Review of 57 patients admitted due to critical ischaemia of upper limb (rest pain, ulcer sepsis, gangrene) 13 due to emboli (10 due to AF, one CHF, one mural thrombus, one stroke-in-evolution) (22.8%) 23 due to arteritis (40.3%) 6 due to atherosclerosis (10.5%) 9 due to trauma (15.8%) Critical ischaemia of the upper limb Journal of the Royal Society of Medicine, Vol 85, May 1992, MS Quraishy, SJ Cawthorn, AEB Giddings

32 184 procedures in 172 patients 35% due to thromboembolic event
A review of over 20 years All operative or endovascular upper limb revascularization between 6/1983 and July 2003 184 procedures in 172 patients 35% due to thromboembolic event 31% due to trauma 17% atherosclerosis Upper limb ischaemia: 20 years experience from a single centre Vascular 2005 Mar-Apr; 13(2): Deguara J, Ali T, Modarai B

33 Axillary artery aneurysm
True aneurysm of UL arteries rare, ~3% Only <15% complicates with ischaemia Aneurysms involving 3rd portion of axillary artery seen in professional baseball pitchers and other overhead throwing athletes Axillary artery aneurysm with distal embolization in a major league baseball pitcher American Journal of Sports Medicine. 35(4):650-3, 2007 Apr. Baumgarten KM. Dines JS. Winchester PA. Altchek DW. Fantini GA. Weiland AJ. Allen A.

34 Hyperabduction syndrome – pectoralis minor
Transient occlusion of axillary artery Hyperabduction, extension and external rotation of shoulder Pectoralis muscle hypertrophy Repetitive stress Intimal wall damage -> thrombosis / aneurysm Axillary artery compression and thrombosis in throwing athletes J Vasc Surg 11: 761–769, 1990 Rohrer MJ, Cardullo PA, Pappas AM, et al:

35 Summary Acute occlusion of upper limb is a rare entity
Evaluation of acute vs chronic ischaemia of upper limb requires thorough knowledge Physical examination and noninvasive tests help locate sites of obstruction, severity of circulatory impairment, distinguish from vasospastic disease Need for further lab tests, angiography or other imaging modality Prompt treatment for critical ischaemia to prevent tissue loss and functional deficit

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