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 Atherosclerosis is rare (vs LL) Differences in pattern of diseases

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

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

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

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

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)

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

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

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)

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

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

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

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

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

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.

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

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

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

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

Follow up CT angiogram:

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

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

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

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

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

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

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

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): 84-91 Deguara J, Ali T, Modarai B

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.

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:

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