Upper limb ischemia


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  • Both main arterial channel and collateral input
  • Upper limb ischemia

    2. 2. CASE 1Sughran bb w/oMuhammad Aslam45/F , a housewife ,resident of faisalabadpresented inemergency
    3. 3. PRESENTATION• Severe pain in right hand-3days• Numbness , coldness and discoloration ofright hand and blackening till the wrist• No h/o intermittent claudication• No h/o direct trauma• H/o of DM -7yrs which is contolled by dietand oral hypoglycemic agents
    4. 4. EXAMINATIONDiscoloration or blackening of right hand till the wristsevere tendernessAbsent brachial, radial, ulnar pulses as compared to leftParasthesiaCapillary refill delayedNo palpable mass or soft tissue swelling over right upperlimbNo ulcerNeurological examination unremarkable
    5. 5. INVESTIGATIONBaselinesCBC- hb-9.2wbc-17.4platelets-288Cholestrol-275Triglycerides-619Echocardiography shows normal sized left ventricle withoverall mild left ventricular systolic dysfunction. Segmentalwall motion analysis shows hypokinesia of distal half of IVS ,apex and apical segments of anterior wallNo evidence of clot, EF: 45%Other baselines were un remarkable
    6. 6. • Doppler studies shows clacification of arterialwalls in brachial artery just above the elbowand lower down in radial and ulnar artery• On color doppler –gradual damping of flowfrom midpoint of brachial artery and absentflow just above the elbow, in radial and ulnararteries
    7. 7. • CT angiography ofright upper limbshows normal outliningof axillary ,brachial uptomidlevel of arm beyondthis brachial artery isthrombosed. Radial andulnar arteries are notoutlined by contrast restof forearm is supplied bycollateral beyond thelevel of thrombosis ofbrachial artery
    8. 8. CASE 2• Asmat bb w/o Altafhussain 40y/F, ahousewife resident ofsialkot presented inoutdoor
    9. 9. PRESENTATION• Pain in right upper limb-1 month• Progressive blackening of right ring , middlefinger-1month• Numbness• h/o intermittent claudication• h/o DM-3months
    10. 10. • Gangrene of distal ringfinger with progressiveblackening if distalmiddle finger• Mild tender• Absent radial,ulnar, andbrachial pulses ascompared to left• Capillary refill delayed
    11. 11. • Baselines were un remarkable• Fasting lipid profile-triglycerides-188(80-150)cholestrol-148(<200)T.cholestrol/HDL.cholestrol:5.9(<5.0)Echocardiography was normal with noevidence of clotEF:65%
    12. 12. • CT angiography :normal aortic arch ,trifurcation , rightsubclavian , axillary artery.Right brachial artery isnormal in upper third, midsegment is small caliberwith total occlusiondistally. Right radial andulnar arteries are notvisualized
    13. 13. UPPER LIMB ISCHEMIA• Is far more uncommon than lower limb ischemia– Upper extremity has good collateral circulation and low rate ofatherosclerosis• Responsible for ~15% of vascular procedures for ischemiclimbs• Of all embolization sites, upper extremity cases accounts foronly 8%• Functional limb impairment occurs in ¾ of cases if leftuntreated• <5% all extremity ischaemia• Small vessel disease involving palmar and digital arteries –majority• <10% of upper-extremity arterial occulsive disease at largevessel
    14. 14. Chronic limb ischemia• Small vessel disease/distal arterial disease-Raynaund’s syndrome-Connective tissue disease: scleroderma-Buergers disease-Ischemia related to occupational injuryrepeated trauma to digital arteriesvibration injuryhypothenar hammer syndrome-Hemotological conditions-Calciphylaxis: renal failure ,diabetes
    15. 15. • Large vessel /proximal disease-Artherosclerosis-Aneurysms-Artheritis : takayasu artheritis,giant cellartheritis-Arterial thoracic outlet syndrome
    16. 16. Acute upper limb ischemia• Main causes of upper limb ischemia:– Embolic occlusion– Acute in situ thrombosis(acute on chronic occlusion)– Traumatic injuries– Aortic dissection– Atherosclerosis and chronic limb ischemia– Subclavian steal s/o– Thoracic outlet s/o– Iatrogenic causes
    17. 17. • 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 atheroscleroticplaques, aneurysm, site of surgery, tumour andtrauma– Arterial emboli to the armJournal of the Royal College of surgeons of Edinburgh 1991; 36: 83-5Vohra R, Lieberman DP
    18. 18. • Classification of acute limb ischemia(according to V. Savelyev )Ia degrees — Sensation of numbness, coolness, paresthesiaIb degrees — PainIIa degrees — ParesisIIb degrees — PlegiaIIIa degrees — Subfascial muscular edemaIIIb degrees — Partial muscular contractureIIIc degrees — Total muscular contracture
    19. 19. • Diagnostic studies:-plethesmography and segmental pressure-duplex ultrasonography-digital pulse volume recordings- CT angiography-MR angiography-selective arteriogram
    20. 20. Treatment flow plan for acute upperlimb ischaemiaHx, medical,occupational/sport, drug, P/E,DopplerRadial and ulnarpulse -veOTAngiogram/CTangiogramAcute on chroniccauses/ proximallesionOT +/- medicaltreatmentOTRadial and ulnarpulse +veSmall arteriallesionsWorkup +medicaltreatments
    21. 21. Management• For limb-threatening ischemia:– Emergency Fogarty catheter embolectomy– +/- vascular bypass grafting if in situ thrombosis ascause of ischemia– If above measures fail, then primary amputation
    22. 22. • Tactics of surgical treatment of sharp arterial impassability.• At embolismes.• - embolectomy - can be deferred at 24 oclock.• IА - - "-• IB - - " - - emergency.• IIА - - "-• IIB - - "-• IIIА - embolectomy+fasciotomy - emergency.• IIIB - - "-• IIIC - primary amputation.Fasciotomy it is carried out only at operations on the bottomfinitenesses.
    23. 23. THANK YOU