1. Interesting Case Rounds Rebecca Burton-MacLeod R4, Emergency Medicine Aug 3, 2006

2. History 81M CC: numbness in left arm and SOBOE HPI: symptoms started suddenly while pt was swimming 4hrs earlier –“clumsiness” in L arm –Diaphoretic, dizzy –2d hx of SOBOE –No specific chest pain

3. History cont’d No palpitations No headache Normal left leg function, normal speech/ vision No previous similar symptoms

4. PMHx Paroxysmal Afib Pacemaker x 10yrs Angina 20yrs prior CHF Scrotal hernia BPH and TURP Meds: –Lasix –Warfarin –Fosinopril –Bisoprolol –Taking all meds regularly

5. On exam: Vitals: Afebrile, P 105 irreg, BP (R arm) 152/80, R 23, sats 92% r/a Normal HS, no murmurs JVP ~3cm ASA, mild bilateral pitting edema to LE Lungs—dec A/E to R base Abdo—soft, non-tender Neuro—CN normal, normal tone, power, reflexes; sl decreased sensation entire L arm MSK—no bony tenderness L arm, full ROM

6. Any thoughts ?

7. Investigations ? CBC, lytes, Cr, INR/PTT, TNT (4hour) EKG CXR

8. Test results Normal CBC Normal lytes, Cr TNT negative INR 1.2 EKG—Afib, T wave inversion in V4-6 (new compared to previous EKG)

9. CXR

10. Any further thoughts ?

11. Management ?

12. Case cont’d No signif improvement Continues to c/o “clumsiness” in L arm

13. CT head

14. Re-examine pt C/o coolness in L arm Decreased radial/brachial pulses in L arm Pt had presented to ED ~1mo ago with epistaxis –Nose packed –Vit K given to reverse warfarin (INR >9)

15. CT angio “saddle-like” intraluminal filling defect in L main PA with extension filling L upper lobe arterial branches

16. CT angio 14.5cm L distal axillo-brachial artery occlusion

17. Problem list CHF Afib PE L ischemic arm Low INR

18. Management Pt admitted to Vascular service Heparinization started Pt underwent L brachial embolectomy the following day Long term anticoagulation (with close monitoring to ensure therapeutic INR !)

19. Acute upper limb ischemia

20. 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

21. Upper extremity anatomy

22. Causes Main causes of upper limb ischemia: –Thromboembolic disease –Traumatic injuries –Aortic dissection –Atherosclerosis and chronic limb ischemia –Subclavian steal s/o –Thoracic outlet s/o –Iatrogenic causes

23. Upper limb ischemia Ali, T et al. Vasc Surg. 2001.

24. Thromboembolic events 62% of pts have associated Afib 84% have associated CAD

25. Differentiation of Thrombus vs. Embolus Embolus –Usual identifiable source for embolus (Afib) –Rarely hx of claudication –Few findings suggestive of occlusive disease –Sharp demarcation of ischemia –Minimal atherosclerosis, sharp cutoff, few collaterals on arteriography Thrombus –Less common to find identifiable source for embolus –Often hx of claudication –Often findings suggestive of occlusive disease (contralateral limb pulses diminished/absent) –Diffuse ischemia –Diffuse atherosclerosis, tapered irregular cutoff, well-developed collaterals on arteriography Rosen’s. Ch 82.

26. Diagnosis 5 P’s: –Pain –Pallor –Pulselessness –Paresthesias –Paralysis

27. Acute limb ischemia

28. 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

29. Heparin ? Should be started immediately 80U/kg IV bolus, then 18U/kg/h maintenance infusion Minimizes clot propagation and obviates further embolism No formal studies done to establish beneficial role

30. GP IIb-IIIa antagonist ? Pilot trial randomized 70 pts to urokinase + abciximab vs. urokinase + placebo –Amputation-free survival at 90d was 96% with GP IIb-IIIa group vs. 80% with placebo –More rapid thrombolysis in first group, but also higher rate of non-fatal major bleeding

31. Thrombolysis ? May be considered in non-limb-threatening ischemia (takes 6-72h for effect) Therefore, most useful if known thrombosis IV thrombolysis initially used, but now mostly replaced by catheter-directed thrombolysis

32. Thrombolysis ? One trial comparing IA streptokinase, IA rt- PA, and IV rt-PA –Angiographic success rates 80% vs. 100% vs. 45% –30 day limb salvage rates 60% vs. 80% vs. 45% respectively Comparison of rt-PA with urokinase showed faster lysis with rt-PA but 24h and 30d clinical success rates were similar Clogett GP et al. Chest. Sept 2004.

33. Surgery vs. thrombolysis Cochrane Review 2006. –5 trials with 1283 participants –No signif difference in limb salvage or death at 30d, 6mos, 1yr –Thrombolysis was significantly associated with higher stroke rates (1.3%), major hemorrhage (8.8%), distal embolization (12.4%) –Concluded insufficient evidence to advocate for universal initial treatment

34. Case conclusion Pt felt to have developed thromboembolic disease resulting in L ischemic arm and PE –Likely due to subtherapeutic INR –? Due to epistaxis and vitamin K administration

35. Vitamin K to reverse anticoagulation DeLoughery TJ et al. Crit Care Clin. July 2005.

36. Questions ?