upper limb ischemia

UPPER LIMB ISCHEMIA

DR SAFIA ZAHIR

CASE 1

Sughran bb w/o Muhammad Aslam 45/F , a housewife , resident of faisalabad presented in emergency

PRESENTATION

• Severe pain in right hand-3days• Numbness , coldness and discoloration of right

hand and blackening till the wrist • No h/o intermittent claudication• No h/o direct trauma• H/o of DM -7yrs which is contolled by diet

and oral hypoglycemic agents

EXAMINATION

Discoloration or blackening of right hand till the wrist severe tenderness Absent brachial, radial, ulnar pulses as compared to left ParasthesiaCapillary refill delayedNo palpable mass or soft tissue swelling over right upper limbNo ulcerNeurological examination unremarkable

INVESTIGATION

Baselines CBC- hb-9.2 wbc-17.4 platelets-288Cholestrol-275Triglycerides-619 Echocardiography shows normal sized left ventricle with overall mild left ventricular systolic dysfunction. Segmental wall motion analysis shows hypokinesia of distal half of IVS , apex and apical segments of anterior wallNo evidence of clot, EF: 45%Other baselines were un remarkable

• Doppler studies shows clacification of arterial walls in brachial artery just above the elbow and lower down in radial and ulnar artery

• On color doppler –gradual damping of flow from midpoint of brachial artery and absent flow just above the elbow, in radial and ulnar arteries

• CT angiography of right upper limb

shows normal outlining of axillary ,brachial upto midlevel of arm beyond this brachial artery is thrombosed. Radial and ulnar arteries are not outlined by contrast rest of forearm is supplied by collateral beyond the level of thrombosis of brachial artery

CASE 2

• Asmat bb w/o Altaf hussain 40y/F, a housewife resident of sialkot presented in outdoor

PRESENTATION

• Pain in right upper limb-1 month • Progressive blackening of right ring , middle

finger-1month• Numbness• h/o intermittent claudication• h/o DM-3months

• Gangrene of distal ring finger with progressive blackening if distal middle finger

• Mild tender• Absent radial,ulnar, and

brachial pulses as compared to left

• Capillary refill delayed

• Baselines were un remarkable• Fasting lipid profile- triglycerides-188(80-150) cholestrol-148(<200) T.cholestrol/HDL.cholestrol:5.9(<5.0) Echocardiography was normal with no evidence of clot EF:65%

• CT angiography : normal aortic arch , trifurcation , right subclavian , axillary artery. Right brachial artery is normal in upper third, mid segment is small caliber with total occlusion distally. Right radial and ulnar arteries are not visualized

UPPER LIMB ISCHEMIA • Is far more uncommon than lower limb ischemia

– Upper extremity has good collateral circulation and low rate of atherosclerosis

• Responsible for ~15% of vascular procedures for ischemic limbs • Of all embolization sites, upper extremity cases accounts for only

8%• Functional limb impairment occurs in ¾ of cases if left untreated • <5% all extremity ischaemia• Small vessel disease involving palmar and digital arteries –

majority• <10% of upper-extremity arterial occulsive disease at large vessel

Chronic limb ischemia

• Small vessel disease/distal arterial disease -Raynaund’s syndrome -Connective tissue disease: scleroderma -Buergers disease -Ischemia related to occupational injury repeated trauma to digital arteries vibration injury hypothenar hammer syndrome -Hemotological conditions -Calciphylaxis: renal failure ,diabetes

• Large vessel /proximal disease -Artherosclerosis -Aneurysms -Artheritis : takayasu artheritis,giant cell artheritis -Arterial thoracic outlet syndrome

Acute upper limb ischemia • Main causes of upper limb ischemia:

– Embolic occlusion– Acute in situ thrombosis(acute on chronic occlusion)– Traumatic injuries– Aortic dissection – Atherosclerosis and chronic limb ischemia– Subclavian steal s/o– Thoracic outlet s/o– Iatrogenic causes

• 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: 83-5Vohra R, Lieberman DP

• Classification of acute limb ischemia(according to V. Savelyev )

Ia degrees — Sensation of numbness, coolness, paresthesiaIb degrees — PainIIa degrees — ParesisIIb degrees — PlegiaIIIa degrees — Subfascial muscular edemaIIIb degrees — Partial muscular contractureIIIc degrees — Total muscular contracture

• Diagnostic studies: -plethesmography and segmental pressure -duplex ultrasonography -digital pulse volume recordings - CT angiography -MR angiography -selective arteriogram

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

OT

Radial and ulnar pulse +ve

Small arterial lesions

Workup + medical

treatments

Management

• For limb-threatening ischemia:– Emergency Fogarty catheter embolectomy– +/- vascular bypass grafting if in situ thrombosis as

cause of ischemia– If above measures fail, then primary amputation

• Tactics of surgical treatment of sharp arterial impassability.

• At embolismes.• - embolectomy - can be deferred at 24 o'clock.• IА - - "-• IB - - " - - emergency.• IIА - - "-• IIB - - "-• IIIА - embolectomy+fasciotomy - emergency.• IIIB - - "-• IIIC - primary amputation.Fasciotomy it is carried out only at operations on the bottom

finitenesses.

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