The treatment of upper limb vascular occlusions using intraarterial thrombolysis

Acute Upper Limb Ischemia: Prompt Surgery and Long-Term Anticoagulation Prevent Limb Loss and Debilitation

Background

Acute upper limb ischemia is an uncommon clinical manifestation of thromboembolism seen predominantly in patients with atrial fibrillation. Treatment can be by conservative or surgical means but the consensus is that after conservative treatment, symptoms still persist. In this series, an attempt was made at limb preservation and return to functional capacity by early surgery in all patients diagnosed with acute limb ischemia.

Methods

Patients referred with upper limb ischemia (22) were stratified into non-acute (6) treated with anticoagulation alone and those with acute ischemia. Sixteen (16) patients, age range 30–92 years (median 62.4 years) comprising mainly females (13), had clinical evidence of severe ischemia and underwent immediate brachial embolectomy with postoperative anticoagulation.

Results

Sixteen patients underwent 20 embolectomies with immediate reperfusion of limbs and relief of symptoms. Two patients had two re-operations each due to recurrent symptoms but both recovered with good outcome, one going on to have an axillary-radial bypass. There was no limb disability nor limb loss, but one postoperative mortality. All other patients were seen at their 1-year review and at 5 years, eleven out of 15 patients were still alive with most resuming an active lifestyle and some returning to work.

Conclusion

Good outcomes were obtained in this series in both the short and long term. Despite one mortality, there was no limb loss nor disability in a mainly elderly population. Prompt surgery and meticulous long-term anticoagulation reduced complications and improved limb salvage rates ensuring that patients had a good quality of life after surgery.

Nonoperative Management of Acute Upper Limb Ischemia

BACKGROUND

Acute upper limb ischemia (AULI) is an uncommon emergency warranting immediate evaluation and treatment. The role of nonsurgical therapies including endovascular techniques, thrombolytics, and anticoagulation remains undefined. The authors systematically reviewed the current literature on the nonsurgical treatment of acute ischemia of the upper extremity.

METHODS

A PubMed and Embase search was conducted, and articles were screened using predetermined criteria. Data collected included patient demographics, cause of upper limb ischemia, type of nonsurgical treatment used, treatment outcomes, and complications. Patients were divided into 4 treatment groups: catheter embolectomy, catheter-directed thrombolysis, endovascular stenting, and anticoagulation/medical therapy alone.

RESULTS

Twenty-three retrospective studies met the search criteria. Of 1326 reported occlusions, 92% (1221) were attributed to thromboembolic disease. The second most common cause was iatrogenic (1.5%). Overall limb salvage rates were excellent with catheter embolectomy (862 of 882 cases, 97.7%) and catheter-directed thrombolysis (110 of 114 cases, 96.5%). Limb salvage rates were also high with anticoagulation/medical therapy (158 of 165 cases, 95.8%), but poor functional outcomes were more often reported.

CONCLUSIONS

High-quality evidence to guide the nonsurgical treatment of AULI is lacking. Retrospective studies support the utility of catheter-based embolectomy and thrombolysis for distal ischemia. Whether a surgical or nonsurgical approach is taken, anticoagulation therapy remains a mainstay of both treatment and prevention of AULI. Because AULI patients often have underlying cardiac and/or systemic disease, a multidisciplinary approach is essential to minimize complications and prevent future occurrences.

Systematic review of the operative and non-operative management of acute upper limb ischemia

Acute upper limb ischaemia (AULI) can be managed surgically, via interventional radiology, and conservatively, but no real guidelines exist for when a conservative approach is appropriate. A systematic review of the literature is presented of the surgical, radiological and conservative management of AULI. A search was performed using the electronic databases Medline and Embase. Interventions and outcomes for each study were recorded. The consensus from the literature review was that operative management (embolectomy) is the most commonly used and best first-line treatment for AULI. No studies that used conservative anticoagulation management as a primary therapy, this mainly being reserved for patients deemed unfit for interventional treatment, appear in the literature. The consensus from the literature is that operative management is the most commonly used and best treatment. However, bias toward using operative management for the fittest patients appears in the literature. It is also possible that conservative management is underreported.

Acute non-traumatic arm ischaemia

BACKGROUND

Much attention has been paid to the management of acute leg ischaemia. Acute arm ischaemia is perceived as less of a problem because the risk of limb loss is lower. After conservative treatment up to half the patients have late symptoms, such as forearm claudication.

METHODS

This study was a review of all published English language data on acute arm ischaemia. The entire Medline database was searched and other references were derived from the material perused. There were no randomized or controlled studies.

RESULTS

The incidence of acute arm ischaemia is one-fifth that of acute leg ischaemia. Patients with arm ischaemia tended to be older with a mean age of 74 years compared with 70 years for acute leg ischaemia. Since the development of the embolectomy catheter, embolectomy can be performed in most patients under local anaesthetic. Collected outcome included successful restoration of the circulation in 65-94 per cent of patients and amputation in 0-18 per cent. The mortality rate ranged from 0 to 19 per cent, despite the use of local anaesthesia, mostly from associated cardiac disease. Management by a vascular specialist may be beneficial, particularly in complex cases.

CONCLUSION

An active approach to the management of acute arm ischaemia is safe and effective and reduces the risk of late disabling symptoms.

Lysis-assisted angioplasty in the treatment of lower-limb arterial thrombosis

This study examined the results in 30 patients treated with lysis-assisted angioplasty and compared them with the results of 30 patients with simple stenotic disease treated by angioplasty alone. One patient died on the day of treatment with lysis-assisted angioplasty from arterial perforation and haemorrhage. Of the remaining 29 patients 16 (55 per cent) were symptomatically improved and 13 had early reocclusion. Six patients developed major complications (two deaths, two major haemorrhage, two cerebrovascular accident). The late results were comparable to those for patients undergoing angioplasty alone. The best outcome was obtained in patients with proximal disease (P < 0.01); poor run-off or critical ischaemia did not preclude a good outcome.

Lower limb intra-arterial thrombolysis

In the UK, approximately 5000 patients present annually with acute lower limb ischaemia. The aetiology is usually thromboembolic disease, other causes include aortic dissection and arterial trauma. Over the past two decades thrombosis has replaced embolism as the principal cause of acute ischaemia, and now accounts for approximately 59% of cases. As a consequence, intra-arterial thrombolysis is being increasingly used as first-line treatment for this condition.