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. 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

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
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

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.

20. 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

21. 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

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

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

24. Follow up CT angiogram:

25. 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

26. 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

27. 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

28. 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

29. 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

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

31. 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

32. 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): Deguara J, Ali T, Modarai B

33. 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.

34. 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:

35. 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