Management of vascular disease of the upper extremity

Bilateral Brachial Artery Disease Presenting with Features of Raynaud's Phenomenon: A Case Report and Review of the Literature

Objective

To present a case of bilateral brachial artery disease presenting with features of Raynaud's phenomenon which was successfully treated with angioplasty and stenting, together with a review of the relevant literature.

Case

A 71-year-old female presented with a one-year history of intermittent pallor of both hands precipitated with cold objects. On examination, bilateral radial pulses were reduced. Prior photos showed pallor of the distal aspect of both palms. Angiogram showed high grade stenosis of the right brachial artery and focal occlusion with likely dissection of the left brachial artery. She underwent angioplasty and stenting for both lesions. She was asymptomatic without further episodes of Raynaud's phenomenon after five months on dual antiplatelet therapy. Upper-extremity vascular stenosis is uncommon. Structural changes in the vessel wall can cause vasospastic attacks, a mechanism described in secondary Raynaud's phenomenon. We hypothesize that these attacks may have been precipitated by the bilateral brachial artery disease. Furthermore, resolution of the symptoms after stent further supports our theory.

Conclusion

Bilateral brachial artery disease is uncommon. Physicians should consider this in patients presenting with Raynaud's phenomenon. Brachial artery stenosis and occlusion is a treatable disease with good symptomatic outcomes after angioplasty and stenting.

Chronic hand ischemia treated with radial artery balloon angioplasty: case report

Although balloon angioplasty in heart and lower extremity vessels has been extensively studied and reported, little information exists regarding its use for digital ischemia in the hand. We report a case of successful balloon angioplasty of the distal radial artery to reverse present and prevent further digital tip cyanosis and necrosis.

Axillary vein thrombosis mimicking muscular strain

Axillary vein thrombosis may occur on strenuous activity with a clinical picture similar to a simple strain. It carries significant morbidity but a good outcome is possible with early treatment. The aetiology, investigation, and treatment are discussed.

Ischaemia of the index finger and thumb secondary to thrombosis of the radial artery in the anatomical snuffbox

We report on nine patients who presented with spontaneous ischaemia of the index finger and thumb over an 11 year period. Arteriography revealed thrombosis of the radial artery in the region of the anatomical snuffbox with evidence of digital artery embolization in each. None had suffered direct trauma to the area or had a demonstrable proximal source for thrombus. While the cause of radial artery thrombosis in our patients in not entirely clear, local inflammation and/or systemic disease may predispose to this entity.

Distal arterial reconstruction using Esmarch's bandage technique to salvage upper extremity function in thoracic outlet syndrome caused by cervical ribs: a report of two cases

We present herein the cases of two patients with thoracic outlet syndrome (TOS) who required arterial reconstruction due to gangrene of the fingers and/or hand. In both patients, the cervical ribs had produced intimal injury of the subclavian arteries, and the successive distal arterial embolism brought about severe ischemia of the affected upper extremity. To treat the TOS, the cervical ribs were resected through a supraclavicular incision. In the first patient, arterial reconstruction was performed from the subclavian artery to the radial collateral artery, a branch of the deep brachial artery, which resulted in minimizing amputation of the gangrenous hand. In the second patient, resection and direct anastomosis of the injured subclavian artery were performed, and bypass surgery from a brachial artery to an interosseous artery was carried out, preserving finger function. Reversed saphenous vein grafts were utilized and Esmarch's bandage technique was applied as a substitute for a vascular clamp in both patients. Following these case reports, we discuss the technique of performing distal bypass in the upper extremities and comment on the usefulness of Esmarch's bandage technique for preserving upper extremity function.

Acquired arteriovenous fistulas in children

Five boys with acquired arteriovenous fistulas are presented; four had factor VIII deficiencies, and one had a hepatic-induced coagulopathy. The cause of the fistula was the trauma induced by single or repeated venous and/or arterial punctures. All five developed a slowly progressive pulsatile mass of over a period of months. Patients with coagulopathies all developed complications with repeated inadvertent puncture of these masses. Clinical examination and magnetic resonance imaging scans clearly highlight this problem. Surgical ligation is recommended for progressive enlargement.

Complexities in the management of arterial compromise due to thoracic outlet syndrome

A patient with arterial compromise secondary to thoracic outlet obstruction is presented and discussed. The case highlights the difficulty in management when initial surgery does not adequately decompress the outlet. It also demonstrates the risk to limb viability that may ensue.

Embolization of a subclavian artery aneurysm with steel coils and thrombin

Subclavian artery aneurysms are rare lesions usually treated by surgical excision or ligation. Steel coils were used successfully to treat a rapidly enlarging subclavian aneurysm in a patient deemed unsuitable for surgery. Because of a profound, uncorrectable coagulopathy, thrombin was required to obtain effective thrombosis.

Chronic upper extremity ischemia: current concepts in management

As a rule, the few innominate or subclavian obstructions that are symptomatic produce neurologic and extremity symptoms that are easily reversed by an extrathoracic surgical approach. Balloon angioplasty is seeing some utility for this problem also. Concomitant carotid disease may be more significant in that its correction may not only prevent stroke but also mitigate symptoms of subclavian steal. The reconstruction of lesions distal to the vertebral artery frequently results in dramatic and durable improvement. Sympathectomy has a valuable role to play in those cases in which restoration of perfusion cannot be complete.

Management of acute ischemia of the upper extremity

Records of 76 patients who presented with ischemia of the upper extremity from 1966 to 1981 were reviewed. Patients were divided into three groups according to cause: Group 1, emboli from the artery; Group 2, ischemia after catheter injury; and Group 3, ischemia due to lesions of the axillary and subclavian arteries. Management varied among the three groups. Long-term anticoagulation therapy was helpful in Group 1 patients in preventing reembolization. Forty percent of patients with catheter-related trauma required angioplasty of some sort in addition to embolectomy. Management of Group 3 patients was most difficult and the results least acceptable (three patients required amputation). Management of this type of ischemia must be individualized; it should vary according to the underlying disorder.