93 raynaud’s syndrome: vasospastic and occlusive arterial disease involving the distal upper...
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93 RAYNAUD’S SYNDROME: VASOSPASTIC AND OCCLUSIVE ARTERIAL DISEASE INVOLVING THE DISTAL UPPER EXTREMITY
Vascular SurgeryStanford Hospital and Clinics
02-13-2006
• Raynaud’s Syndrome – episodic pallor or cyanosis of the fingers
due to vasoconstriction of small arteries or arterioles in the fingers
occurring in in response to cold or emotional stress
• Raynaud’s disease – primary vasospastic disorder without
identifiable underlying cause
• Raynaud’s phenomenon – vasospasm secondary to an underlying
condition or disease
DEFINITION
• Induced by cold exposure
• Sudden onset of waxy pallor of digits
• Cyanosis follows the pallor
• Resolving with hyperemia and rubor of the skin
• Female > male (4:1 to 1.6:1)
CLINICAL PRESENTATION
• Vasospastic attacks precipitated by exposure to cold or emotional
stimuli
• Symmetrical or bilateral involvement of the extremities
• Absence of gangrene
• Symptom present for a minimum of 2 years
• Absence of any other underlying disease
DIAGNOSIS OF PRIMARY RAYNAUD’S SYNDROM
• “Hunting response” – responding to cold temperature, arterial
vasoconstriction and dilatation alternates. Frequency about every
30 seconds to 2 minutes
BLOOD FLOW REGULATION OF FINGERS
• Existing fixed vascular obstruction
• Decrease the threshold for cold-induced vasospasm
• Conditions causing vessel lumen narrowing - Scleroderma
• Increasing viscosity - Myeloma
SECONDARY VASOSPASTIC DISORDER
• Direct compression - Aberrant right subclavian artery, Thoracic outlet
syndrome
• Embolization – Thoracic outlet syndrome, atherosclerosis
• Deep and superficial palmar arches
ANATOMY OF UPPER EXTREMITY AND POTENTIAL ETIOLOGY
ABERRANT RIGHT SUBCLAVIAN A.
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
NORMAL PALMAR ARCHES
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
VARIATIONS OF PALMAR ARCHES
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
PRIMARY VS. SECONDARY RAYNAUD’S
Table 93-1. Clinical Features to Distinguish Primary from Secondary Raynaud's Syndrome
TYPE GENDER OTHER FEATURES
Primary Usually female
Age < 45 years
Vasospasm of multiple or all digits
Normal vascular examination
No skin abnormalities
Normal laboratory studies
Secondary Male or female
Any age
Single digit involved
Abnormal pulse examination
Vascular laboratory abnormalities
Positive autoantibodies
GENERAL CATEGORY SPECIFIC DISORDERS
Connective tissue disease Scleroderma, CREST
Systemic lupus erythematosus
Rheumatoid arthritis
Mixed connective tissue disease
Overlap connective tissue disease
Dermatomyositis and polymyositis
Vasculitis (small, medium-sized vessel)
Occlusive arterial disease Atherosclerosis
Thromboangiitis obliterans (Buerger's disease)
Giant cell arteritis
Arterial emboli (cardiac and peripheral)
Thoracic outlet syndrome
Occupational arterial disease Hypothenar hammer syndrome
Vibration induced
Drug-induced vasospasm β-Adrenergic blocking drugs
Vasopressors
Ergot
Cocaine
Amphetamines
Vinblastine/bleomycin
Myeloproliferative and hematologic disease Polycythemia rubra vera
Thrombocytosis
Cold agglutinins
Cryoglobulinemia
Paraproteinemia
Malignancy Multiple myeloma
Leukemia
Adenocarcinoma
Astrocytoma
Infection Hepatitis B and C antigenemia
Parvovirus
Purpura fulminans
• Investigate causes for secondary Raynaud’s
• Exam heart
• Upper extremity vascular exams
PHYSICAL EXAMINATION
• To eval large vessel occlusive diease
• Measure systolic pressures at brachial, upper elbow, and wrist
• Abnormal – difference > 10 mm Hg
• Wrist-brachial ratio - > 0.8
SEGMENTAL PRESSURE MEASUREMENT
• Normal finger-brachial index – 0.8 to 1.27
• Occlusive disease – diff. > 15 mm Hg, or, finger SBP<70 mm Hg
• Measure while changing finger temperature
FINGER SYSTOLIC BLOOD PRESSRES
• Cold recovery time – NL <10 mins
• Laser Doppler Flux
• Duplex ultrasound
• Contrast Angiography – gold standard
OTHER TESTS
• Symptomatic UE ischemia is rare – 5%
• Most are primary Raynaud’s syndrome – medical management
• Acute ischemia – 5 “P”s
• Chronic ischemia – equivalent of claudication (dominant hand more)
• Tissue loss are rare – rich collaterals
Axillary A. ligation – 10% limb loss
Brachial A. ligation – 3-5% lead to gangrene
OVERVIEW AND PRESENTATION
• Atherosclerosis
Rare to upper extremity
Occasionally seen in axillary, brachial, radial and ulnar A.
• FMD
• Hypothenar hammer syndrome – distal ulnar A
INTRINSIC ARTERIAL DISEASE
• Iatrogenic
Brachial A. – most common (0.9-4% after cath)
Axillary A. – 0.8% thrombotic complications
Radial A. – 5-40% (hand ischemia 0.3-0.5%)
• Non-iatrogenic
Blunt – intimal disruption, early/late presentation
Traction – intimal disruption (mild), arterial disruption (severe)
Penetrating – direct/blast injury
TRAUMA
• Account for 25% total embolic event
External source – cardiac, aortic arch, subclavian A pathology
Intrinsic source – intimal flaps, stenosis, injection
• Most common source – cardiac (A-Fib)
• Most common location – Brachial A. (60%)
EMBOLI
• Proximal portion – transverse incision at deltopectoral groove
• Distal portion – axillary or upper arm incision
• End to end anastomosis
• Saphenous vein is the graft of choice
• Chronic occlusion – carotid-to-brachial bypass, or axillary-to-
brachial bypass
AXILLARY ARTERY
• Embolectomy – incision below the antecubital fossa
• Incision right on the projected injury site
• Long segment occlusion – Saphenous vein graft
• Direct end-to end anastomosis
BRACHIAL ARTERY