Management of Acute Upper Extremity Ischemia: Treatment Strategies and Outcome

Abstract

The aim of the study was to evaluate etiology, type of procedure, limb salvages attempted, and outcomes in acute upper limb ischemia (AULI). Patients from January 2013 to December 2014 with AULI (excluding trauma, iatrogenic) admitted at our hospital (Jain Institute of Vascular Sciences, Bengaluru, India) were included in the study. The analysis included 43 patients (53% males), mean age of 51 ± 12 years. Three patients presented ≤6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. AULI constitutes ∼12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.