Nonoperative Management of Acute Upper Limb Ischemia

Outcomes of Surgical Revascularization for Acute Upper Limb Ischemia- A Single-Center Retrospective Analysis

BACKGROUND

Acute upper limb ischemia (AULI) is a medical emergency with high perioperative complication rates; however, these are poorly reported. The aim of this study is to report the complication rates following surgical revascularization in AULI.

METHODS

Retrospective analysis of all patients undergoing brachial embolectomy for AULI from January 2010 to October 2021 was included. Data for baseline demographic characteristics, site of arterial occlusion, cancer status, and the potential underlying etiology were included. Outcomes included technical success, early reintervention, local and systemic complications, functional limb outcome at follow-up, and amputation.

RESULTS

96 patients were identified. Computed tomography angiography was the first line diagnostic imaging modality, with the brachial bifurcation as the most common location for obstruction. The initial technical success rate was 76.4% (n = 73). Major adverse events occurred in 11.5% patients (n = 11); 8.3% had perioperative stroke and 7.3% resulted in in-hospital death (4.2% had both). Local complications occurred in 24%; 7.3% had site hematoma, 11.5% had early thrombosis, and 4.2% had 30-day thrombosis. 2.1% resulted in amputation. No variables were identified as having significant association with local surgical complications.

CONCLUSIONS

AULI is often associated with underlying systemic and cardiac disorders. An evidence based approach to guide the nonoperative management of AULI is lacking. In appropriately selected patients, Fogarty thrombectomy has a reasonable technical success rate; however, the associated perioperative complication rate is high, both locally and systemically. Further studies of larger sample size are needed to identify negative predictors and reduce perioperative complications in this challenging cohort.

Anticoagulation in embolic acute limb ischaemia-an observational study

The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Material and methods: Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. Results: A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Conclusions: Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.

Thoracic Outlet Syndrome-An Uncommon Cause of Acute Upper-Limb Ischemia

ABSTRACT

Acute upper-limb ischemia is usually secondary to thromboembolic occlusion. The heart is the usual source of emboli in the majority of patients. In a small percentage of cases, the thromboembolic process may start in a proximal large-sized artery, such as the subclavian artery, resulting in thromboembolic occlusion of the upper extremity's small peripheral arteries. In patients with acute upper-limb ischemia, a systematic color flow Doppler ultrasound of the upper extremity arteries may reveal thoracic outlet syndrome as the underlying cause. This pictorial review presents a systemic color flow Doppler approach to evaluate upper extremity arteries in patients with thoracic outlet syndrome presenting as acute ischemia.

Endovascular Thrombolysis in Hypothenar Hammer Syndrome: A Systematic Review

Objectives: Hypothenar hammer syndrome (HHS) is a rare vascular disease caused by blunt trauma of the hypothenar region. The optimal therapeutic strategy remains debatably since no large comparative studies are available yet. We want to evaluate the effectiveness of intra-arterial thrombolysis on angiographic and clinical outcome parameters in patients with HHS by performing a systematic review of the existing literature.

Methods: A literature search of PUBMED/MEDLINE and SCIENCE DIRECT databases was performed up to May 2021.

Results: In total, 16 manuscripts with 43 patients were included in the systematic review. Intra-arterial thrombolysis led to angiographic improvement in 29 patients (67.4%) and to clinical improvement in 34 patients (79.1%). Deterioration of arterial perfusion or clinical symptoms after thrombolysis were absent. Post-interventional complications were reported in only one patient (2.3%) without any bleeding complication. Logistic regression analyses demonstrated that a combined administration of fibrinolytics and heparin was associated with a significantly improved arterial patency [OR 12.57 (95% CI 2.48–97.8), p = 0.005] without significant amelioration of clinical symptoms [OR 3.20 (95% CI 0.6–18.9), p = 0.172]. The use of rt-PA compared to other fibrinolytics and a prolonged thrombolysis duration of more than 24 h did not show statistically significant effects. Intra-arterial thrombolysis was significantly less effective in patients who had undergone thrombolysis with a delay of more than 30 days regarding clinical improvement [OR 0.07 (95% CI 0.00–0.54), p = 0.024].

Conclusions: Intra-arterial thrombolysis with a combination of fibrinolytics and heparin is an effective and safe therapeutic option in patients with acute HHS.

Outcomes of Acute Limb Ischaemia in Patients with Underlying Malignancy: A Systematic Review

OBJECTIVE

Previous studies have demonstrated amputation and mortality rates to be 14.3% - 30% and 11.4% - 28.9%, respectively, for all patients presenting with acute limb ischaemia (ALI). Rates of ALI are higher in patients with malignancy than in those without. Despite this, there remains uncertainty with regards to the most appropriate management for patients with cancer presenting with ALI. This is because of previously published high rates of associated morbidity and mortality in this population. The aim of this review was to summarise the available evidence reporting on outcomes of ALI in patients with underlying malignancy.

METHOD

A systematic review was performed in August 2020 in accordance with the PRISMA guidelines. The Medline, Scopus, Cochrane, and Embase databases were searched with the following search string ((acute limb ischaemia) OR (acute limb ischemia)) AND ((cancer) OR (malignancy)). A total of 849 papers were identified and reviewed; six studies were included. Studies were assessed for bias using the National Institute of Health/National Heart, Lung and Blood Institute Quality Assessment Tool. Data including demographics, Rutherford classification, baseline performance scores, method of revascularisation, and peri-procedural outcomes were extracted and analysed. Data were pooled based on outcomes of interest and pooled prevalence was reported with 95% confidence intervals (CI).

RESULTS

Six studies with 284 patients with cancer were included for analysis. The pooled overall risk of amputation was 15% (95% CI 5.9 - 26.9). The pooled 30 day mortality rate was 24% (95% CI 14.7 - 34.6).

CONCLUSION

Despite limitations of interstudy selection bias and some clinical heterogeneity, the included studies demonstrated acceptable short and medium term outcomes for patients with cancer undergoing revascularisation for acute limb ischaemia. This is in line with current recommendations that patients with underlying malignancy should be considered strongly for revascularisation.

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.

Recurrent upper extremity acute limb ischemia secondary to retained axillary polytetrafluoroethylene cuff causing axillary stump syndrome

Acute limb ischemia of the upper extremity is less frequently encountered than in the lower extremity. The etiology is typically cardioembolic. Axillary-femoral stump syndrome is a rare complication associated with an occluded axillary-femoral bypass graft. We present the case of recurrent acute limb ischemia of the upper extremity whose embolic source was a retained cuff of a previously explanted axillary-profunda bypass graft. The patient failed anticoagulation after an initial embolectomy and after a recurrent embolism from the retained cuff, ultimately required cuff exclusion with a covered stent.

Externally Supported Extra-anatomical Venous Bypass to Treat Upper Limb Ischemia with Shoulder Prosthetic Infection

To report a case of acute arm ischemia and prosthetic shoulder infection treated by extra-anatomical great saphenous vein graft with external vascular scaffolding. A 65 year-old man with multiple surgical interventions for soft tissue sarcoma of the right shoulder, local radiotherapy with residual brachial plexus neuropraxia, was referred to our attention for signs of arm ischemia. Two weeks before, the patient was submitted to prosthetic shoulder replacement complicated with prosthetic infection. Considering the mechanism of vascular injury, an open surgical revascularization was planned with a deliberate avoidance of the natural anatomic pathway to reduce the risk of graft infection. Consequently, after the complete removal of infected shoulder prosthesis and placement of antibiotic spacer, an axillarbrachial artery bypass using great saphenous vein was performed using a new braided cobalt chrome kink resistant external vascular support to prevent compression, also considering the extra-anatomical position of the graft. At 12 months' follow-up, patient was in good clinical condition with complete resolution of arm ischemia; computed tomographic angiography and duplex scan revealed patency of the graft with excellent distal perfusion. The new external vascular support seems to be useful and feasible for preventing compression of extra-anatomical venous bypass.

Successful Endovascular Treatment of Acute Thromboembolic Upper Limb Ischemia in a Patient with Atrial Fibrillation

Acute limb ischemia represents a medical emergency that requires prompt diagnosis and treatment to preserve the viability of the affected tissue. The majority of the ischemic events are thrombotic in nature, especially in patients with atrial fibrillation. To date, surgical thrombectomy is usually used for the treatment of acute thromboembolic upper limb ischemia. Herein, we present a case of an 88-year-old patient who presented with right upper limb pain, pulselessness, and paresthesia. Duplex sonography revealed thrombotic occlusion and the absence of flow in both the ulnar and radial arteries. Electrocardiogram exhibited atrial fibrillation with a heart rate of 88 bpm. Antegrade puncture of the brachial artery was performed, and digital subtraction angiography confirmed fresh occlusion of the ulnar and radial arteries with some residual flow in the accessory brachial artery. Thrombus aspiration using a 6-Fr Eliminate aspiration catheter (Terumo Interventional Systems, Eschborn, Germany) was repeatedly performed, resulting in thrombolysis in myocardial infarction (TIMI) III antegrade flow to the right hand, promptly filling of the palmar arch and retrograde filling of the ulnar artery. Pain and paresthesia immediately resolved without need for further pharmacological interventions. The patient was discharged without functional deficits of his right hand, and duplex sonography after 4 weeks and 6 months revealed triphasic flow of the brachial and radial arteries and retrograde flow of the ulnar artery.

A Population-Based Study of Incidence, Presentation, Management and Outcome of Primary Thromboembolic Ischemia in the Upper Extremity

OBJECTIVES

To investigate the epidemiology of acute upper limb thromboembolism in a well-defined Norwegian population.

METHODS

This study was a retrospective, single-center, observational population-based cohort study of acute upper limb thromboembolism. The study included all patients from the hospital's primary catchment area from January 2000 to December 2015. Age- and gender-adjusted incidence rates were calculated using population demographics from Statistics Norway.

RESULTS

A total of 54 patients were identified, of which 49 were included in the analyses: 27 (55%) females (median age 83 years, range 40-96) and 22 (45%) males (median age 70 years, range 42-95) (P = .053). The adjusted incidence rate for the period was 1.6 patients per 100,000 inhabitants per year (95% confidence interval 1.2-2.2) and did not change significantly during the period studied. Atrial fibrillation was detected by electrocardiography in 30 (61%) patients; in this group, 10 patients were on warfarin but only two had an international normalized ratio > 1.9 and the remaining 20 were not anticoagulated. Altogether, 38 (78%) patients underwent surgery, 1 (2%) was treated with thrombolysis, and the remaining patients were treated conservatively; no amputations were performed. Four patients (8%) died within 30 days, and 12 of the surviving 45 patients (27%) had recurrent thromboembolism.

CONCLUSION

The incidence rate was stable during the study period. Patients with upper limb thromboembolism due to atrial fibrillation were inadequately anticoagulated. One in four patients experienced a recurrent thromboembolic event. Lifelong anticoagulation should be considered in all patients with upper limb thromboembolism.

Acute Limb Ischemia

Acute limb ischemia is technically defined as ischemia of the lower extremities lasting 14 days or less. The condition affects between 15 and 26 persons per 100,000 each year in the United States. The associated morbidity and mortality is extremely high, with 1-year mortality rates reported at over 40%. Acute limb ischemia is 20 times more common in the lower extremities than the upper extremities. Both interventional radiologists and vascular surgeons bring unique skills to the table in caring for these patients, and therefore should approach the care of these patients in a multidisciplinary manner to ensure the best outcomes for each patient. Patients should be classified according to the Rutherford classification scale for acute limb ischemia. Catheter-directed thrombolysis can be a viable treatment alternative for these patients, offering a minimally invasive option to patients with outcomes similar to surgery. It is important to know the presentation, physical examination, risks and benefits, as well as the techniques and equipment required to treat patients with acute lower limb ischemia.