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Acute occlusive disease of upper limb

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

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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. 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 Innominate artery Subclavian artery 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

  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.

  17. 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

  18. 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

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

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

  21. Follow up CT angiogram:

  22. 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

  23. 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 armJournal of the Royal College of surgeons of Edinburgh 1991; 36: 83-5Vohra R, Lieberman DP

  24. 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

  25. 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

  26. 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

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

  28. 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 limbJournal of the Royal Society of Medicine, Vol 85, May 1992, MS Quraishy, SJ Cawthorn, AEB Giddings

  29. 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 centreVascular 2005 Mar-Apr; 13(2): 84-91Deguara J, Ali T, Modarai B

  30. 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.

  31. 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:

  32. 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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