Joint Hospital Surgical Grand Round- Acute Upper Limb Ischaemia

1. Joint Hospital Surgical Grand Round-Acute Upper Limb Ischaemia Dr Cheung Wai Hung, Timothy Surgery, Princess Margaret Hospital

2. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

3. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

4. Definition of acute limb ischaemia • Inter-Society Consensus for the Management of Peripheral Arterial Disease 2007 (TASC II) • “……sudden decrease in limb perfusion that causes a potential threat to limb viability …..” • “……later than two weeks after the onset of the acute event are considered to have chronic limb ischemia.” [1] https://medlicker.com

5. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

6. Epidemiology • Incidence of 1.3 per 100,000 [2] • Relative incidence 15%-18% of lower limb ischaemia [3] • Mortality rate around 12% • Slight female predominance • Mean age is at 70s • Right upper limb is twice affected as left side [1] http://s3.amazonaws.com/libapps/accounts/13182/images/epidemiologyMED.jpg [2] Stonebridge PA, Clason AE, Duncan AJ, Nolan B, Jenkins AM, Ruckley CV. Acute ischaemia of the upper limb compared with acute lower limb ischaemia: a 5-year review. Br J Surg. 1989;76:515-516. [3] Galbraith K, Collin J, Morris PJ, Wood RF. Recent experience with arterial embolism of the limbs in a vascular unit. Ann R Coll Surg Engl. 1985;67:30-33.

7. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

8. Causes • Up to 70% cause as embolism [1] • Up to 70% of embolism is from Cardiac source [1] • Iatrogenic arterial catheterization can cause trauma to vessel [1] P. EYERS, J.J. EARNSHAW. Review: Acute non-traumatic Arm Ischaemia. British Journal of Surgery 1998., 85, 1340-1346

9. Common sites for embolic acute upper limb ischaemia (AULI) 11.7% 23% 61% 23% 1.6%

10. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

11. Clinical presentation • Classical 6 Ps • Pain • Pallor • Pulselessness • Poikilothermia • Paresthesia • Paralysis

12. Examination • Rutherford classification • Classified into 3 categories • Viable, threatened and irreversibly damaged • Assessment of sensory, power and pulse doppler signal

13. Examination

14. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

15. Diagnosis • Mainly by Clinical diagnosis • Doppler USG can provide quick bedside information • Imaging provide further information: • Weigh against urgency of revascularization • CTA, DSA, MRA

16. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

17. Treatment for embolic AULI • Once clinical diagnosis is made, patientshouldimmediately receive anticoagulation by heparin bolus follow by infusion • Exclusion of contraindications • Recommended by: • 2012 American College of Chest Physicians (ACCP) guideline on antithrombotic therapy for peripheral artery occlusive disease • 2007 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) consensus document on the management of peripheral artery disease (PAD)

18. Treatment of AULI • Embolism • Conservative • Surgical embolectomy • Endovasculartreatment • Thrombosis • Trauma • Fasciotomy maybe needed for compartmentsyndrome

19. Conservative management

20. Conservative management • Pre surgical embolectomy era • Different strategies including: • Anticoagulation • Rehydration, optimize cardiac output, Warming • Vasodilatation, Avoidance of vasopressor • Amputation rate up to 8% • Up to 50% of patient with residue functional loss

21. Surgical Embolectomy

22. Surgical embolectomy for AULI • S-shaped incision/ Lazy-S incision at antecubital fossa • medially in the groove in the arm • carried transversely across the elbow crease then inferiorly on the lateral forearm. • Fr 2/3/4 Forgarty catheter pass proximally or distally [1]https://www.youtube.com/watch?v=wv6fwAnV7lI

23. Surgical embolectomy • Post procedure back bleeding may not be a reliable guide to distal patency [1] • TASC II recommendation No.32 states that • “….Unless there is good evidence that adequate circulation has been restored, intraoperative angiography should be performed to identify any residue occlusion or critical arterial lesions requiring further treatment….” [1] Mckenzieetal,valueofintraoperativeangiography in arterial embolectomy surgery. Can J Sur 1976:19:223-6

24. Surgical embolectomy

25. Surgical embolectomy • Systematic review published in 2016 • Literature search in Embase and Pubmed • 23 retrospective studies were included • No prospective or comparative studies available • Studies were categorized into main groups: • Catheter embolectomy: 13 • Catheter directed thrombolysis: 8 • Anticoagulation and medical therapy: 9

26. Surgical embolectomy • Overall Limbsalvagerate 97.7% • Functional deficit: • Mild 13-20% • Severe 3-5% • Local complications as high 20.3% • Mortality 5.6% • Mostly caused by systemic complications e.g., cardiovascular, cerebralvascular

29. Routine use intra-operative completion angiography?

30. Routine use intra-operative completion angiography? • Retrospective study published in 2012 • 100 patient in 18-year with catheter thromboemloectomy • Divided into 2 groups • Selected use of angiogram (A), N=50 • Routineuse of angiogram (B), N=50 • Similar demographics with no significant difference

31. Routine use intra-operative completion angiography? • Higher rate of extension of procedure (26.0% vs. 4.0%, P = 0.002). • At 24 months after embolectomy, • Lower incidence of re-occlusion (12.0% vs. 2.0%, P = 0.05) • No statistical difference in mortality (P > 0.05). • No amputation required in both groups

33. Endovascular treatment

34. Catheter directed thrombolysis • First line treatment in acute lower limb ischaemia • Can reach locations that were difficult for embolectomy catheter • Thrombolytic agents: • Streptokinase • Urokinase • Recombinant tissue plasminogen activator • Require close monitoring, e.g., ICU • Post procedure angiogram for reassessment [1] http://www.cirse.org/index.php?pid=1072

35. Catheter directed thrombolysis • Well established evidence for acute lower limb ischaemia • Landmark randomized prospective studies, e.g. • Thrombolysis or Peripheral Artery Surgery (TOPAS) trial • Surgery versus Thrombolysis for Ischemia of the Lower Extremity (STILE) trial • However, no large scale comparative studies available for acute upper limb ischaemia

36. Catheter directed thrombolysis

37. Catheter directed thrombolysis • Overall Limbsalvagerate 96.5% • No consistent data on functional deficits • Local complications • Increased complications for proximal lesions, e.g. cerebral haemorrhage • No comparison between different thrombolytic agents

41. Endovascular treatment • Retrospectivenon randomizedstudies, published 7/2017 • 18 patients from 1/2005 to 4/2016 • All patients are Grade IIa or IIb • 3 main groups • Catheter directed thrombolysis based (CDT): 9 • Percutaneous aspiration based (PAT): 6 • Angioplasty based: 3 (Subclavian artery or arterial dissection)

42. Endovascular treatment

43. Endovascular treatment • Clinical and technical success rate 100% • Amputation and mortality 0% • Major complication 10% • Cerebellar haemorrhage • Ulnar artery pseudoaneurysm • PAT use less thrombolytics than CDT • 40,000U Vs 246,667U, p = 0.004 • Combination of endovascular techniques is important

44. Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

45. Conclusion - I • AULI is not uncommonly seen in clinical practice • Clinical emergency with possible great functional impact • Lack of guidelines • Prompt recognition & diagnosis with history and physical examination • Weigh against urgency of revascularization for imaging • Anticoagulation should be started if no contraindication

46. Conclusion - II • Surgical embolectomy is well established treatment • Completion angiography can decrease re-occlusion rate • Endovascular treatment showed promising result and can be used as adjunct therapy • Cardiac workup is warranted as most case is caused by cardio-embolic event

47. Reference • Hernandez-Richter T, Angele MK, Helmberger T, Jauch KW, Lauterjung L, Schildberg FW. Acute ischemia of the upper extremity: long-term results following thrombembolectomy with the Fogarty catheter. Langenbecks Arch Surg. 2001;386:261-266. • E.C. James, N.T. Khuri, C.W. Fedde, et al.Upper limb ischemia resulting from arterial thromboembolismAm J Surg, 137 (1979), pp. 739-744 • H. HaimoviciCardiogenic embolism of the upper extremityJ Cardiovasc Surg, 23 (1982), p. 233 • Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, TASC II Working Group J Vasc Surg. 2007;45 Suppl S:S5. • Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.Alonso-Coello P, Bellmunt S, McGorrian C, Anand SS, Guzman R, Criqui MH, Akl EA, Olav Vandvik P, Lansberg MG, Guyatt GH, Spencer FA, American College of Chest Physicians Chest. 2012;141(2 Suppl):e669S. 

48. Reference • Does routine completion angiogram during embolectomy for acute upper-limb ischemia improve outcomes? Zaraca F1, Ponzoni A, Sbraga P, Stringari C, Ebner JA, Ebner H. Ann Vasc Surg. 2012 Nov;26(8):1064-70. doi: 10.1016/j.avsg.2011.12.012. Epub 2012 Jun 26. • Schrijver AM, de Borst GJ, Vos JA, et al. Catheter-directed thrombolysis as first line treatment of acute nontraumatic upper extremity ischemia. J Vasc Surg. 2011;53:58S. • Nonoperative Management of Acute Upper Limb Ischemia Victor W. Wong1, Melanie R. Major1, and James P. Higgins1 HAND 2016, Vol. 11(2) 131 –143 • Systematic review of the operative and non-operative management of acute upper limb ischemia E. Jane H.TurnerPhD AlexanderLohFRCS AdamHowardFRCS Journal of Vascular Nursing Volume 30, Issue 3, September 2012, Pages 71-76 • Mckenzieetal,valueofintraoperativeangiography in arterial embolectomy surgery. Can J Sur 1976:19:223-6

49. Thank you