Acute Upper Limb Ischemia Research Articles

Adverse Events in Open Surgical vs. Ultrasound-Guided Percutaneous Brachial Access for Endovascular Interventions.

Background: Advances in endovascular interventions have made endovascular approaches the first option for treating peripheral arterial diseases. Although radial artery access is commonly used for coronary procedures, the common femoral artery remains the most frequent site for endovascular treatments due to better ergonomics and proven technical success. Meanwhile, data on using upper extremity access via the brachial artery during complex endovascular aortic interventions are lacking. This study aimed to compare the incidence of access site complications between ultrasound-guided percutaneous brachial access (UPA) and open surgical incisional brachial access (OSA) in the management of peripheral arterial diseases. Methods: Patients who underwent treatment for peripheral arterial and aortic disease using brachial access from 2019 to 2023 were included in this study. The primary endpoint was the complication rate at the access site 30 days postoperatively. Access-related complications included bleeding requiring re-exploration, acute upper limb ischemia, thrombosis, pseudoaneurysm, arteriovenous fistula, and nerve injury associated with the brachial access. Results: Brachial access was performed on 485 patients (UPA, n = 320; OSA, n = 165). The mean operation time was 164.5 ± 45.4 min for the percutaneous procedure and 289.2 ± 79.4 min for the cutdown procedure (p = 0.003). Postprocedural hematoma occurred in 15 patients in the UPA group and 2 patients in the OSA group (p = 0.004). Thromboembolic events were observed in 9 patients in the percutaneous group and 3 patients in the OSA group. Reoperation was required for 23 patients in the percutaneous group and 8 patients in the cutdown group. Conclusions: The findings indicate that patients undergoing endovascular arterial interventions have a higher rate of brachial access complications in the UPA group compared to the OSA group.

A Case of Arterial Thoracic Outlet Syndrome Thrombus Extending to Juxtavertebral Artery

Arterial thoracic outlet syndrome (TOS) constitutes less than 1%, involving the second part of the subclavian artery (SCA). It can present as an acute upper limb ischemia or aneurysm formation. Here is a case of a 29-year-old male presented with complaints of rest pain over the left hand for the past 2 weeks. Upon evalution, found to have bilateral cervical rib with left subclavian artery occlusion. Treated by cervical rib excision decompression of scalene triangle, subclavian endarterectomy and left brachial embolectomy. Arterial TOS secondary to the cervical rib is rare; pathology involving this external compression results in repeated trauma in the intima of the SCA, resulting in subclavian stenosis, poststenotic dilatation, thrombosis, and aneurysm formation with mural thrombus and distal embolization. Symptomatic cases need decompression +/- arterial repair.

When Time is Limb: A Rare Case of Acute Upper Limb Ischaemia

Acute limb ischemia (ALI) is a medical emergency with a time-sensitive outcome. Acute upper limb ischemia (AULI) is less common than lower limb ischemia, and relatively few cases have been reported. It may cause significant disabilities and severe functional impairment even in the absence of overt tissue loss. Six hours window of presentation yielded a better outcome. However, diagnosing and treating within the time frame has always been a challenge. A high index of suspicion assisted with Doppler study in a limited-resources health centre is ofsound importance as limb ischemia might be mimicked by other diseases. We illustrated a case of AULI with atypical presentation and successful revascularisation intervention.

Acute limb ischemia due to left brachial artery occlusion in a 40-year-old female patient: a case report

Acute upper limb ischemia (ALI) due to brachial artery occlusion is a rare but catastrophic condition that poses a significant threat to limb viability and can result in limb amputation or death. Accurate diagnosis and timely intervention are crucial to avoid catastrophic consequences. Literature on ALI due to brachial artery occlusion is scant and usually related to atrial fibrillation. We report a 40-year-old female presented with sudden onset left upper limb pain, change in color, and neurological deficits in the last three days. A color Doppler ultrasound revealed a complete occlusion of the left brachial artery with echogenic thrombosis suggestive of ALI. The patient urgently underwent a thrombectomy with an uneventful outcome. In conclusion, even though ALI due to brachial artery occlusion is rare, a heightened level of suspicion, precise diagnosis, and timely management are essential to prevent any fatal consequences.

Long-term Outcomes of Nonoperative Management of Acute Nontraumatic Upper-limb Ischemia – A 5-years Follow-up

Abstract Background: Acute upper-limb ischemia (AULI) is a sudden loss of perfusion to the affected limb. The annual incidence of AULI has been reported as 1.3 cases/100,000 patients. It can be due to vaso-occlusive or vasospastic disorders. It is often the result of thromboembolic disease, trauma, or iatrogenic factors. AULI has multiple modalities of treatment including surgical and nonsurgical options. Materials and Methods: Our study is a retrospective study where patients who have been conservatively treated at a single center between January 2015 and January 2018 were followed up for 5 years. Results: The analysis included 31 patients (61.3% males), with a mean age of 57 years. Only three patients presented within 6 h, and 16 patients presented more than 12 h after symptom onset. Of the 31 patients, 19% had a cardiac source of embolus, 65% had arterial thrombosis, and 16% had other etiologies. The axillary and brachial arteries were noted to be the most affected sites. All the patients underwent conservative management with anticoagulation. Results of this study showed that patients had amputation-free survival with improvement in clinical symptoms and functional outcomes at 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years. None of the patients required a surgical intervention for revascularization. At the end of 5 years of follow-up, two patients underwent partial amputations of one or more fingers, and limb salvage was achieved in all the patients. Most of the patients improved in terms of limb functionality from Grade 3 or Grade 4 at the time of presentation to Grade 1 according to functionality grading. Conclusion: Patients treated with conservative management for AULI have good amputation-free survival and good functional outcomes after 5 years as per our study.

Saddle Shaped Thrombus at Subclavian-Vertebral Artery Junction

Acute upper limb ischemia is an uncommon but dreaded cardiovascular emergency. Severity of symptoms is dependent upon the site of the arterial occlusion and the extent of the collateral blood supply around the shoulder and elbow region. The most common cause of occlusion in subclavian artery is thromboembolic occlusion. Rheolytic pharmaco mechanical thrombectomy effectively removed the heavy thrombus after placing an embolic protection device in the vertebral artery. Good recanalization was achieved precluding the need of stenting.

A Single-center, Seven Years Retrospective Study to Analyze the Outcomes of Acute Upper Limb Ischemia (AULI) in Northern India

ABSTRACT Background: Acute upper-limb ischemia (AULI) is not always as limb-threatening as those in the leg, so thrombo-embolectomy is not always as necessary for limb salvage. Objective: To evaluate “the outcomes of limb and life at the end of one month, in patients with AULI” and to analyze the following factors: presentation from the time of the acute event, evaluation of limb at the time of presentation regarding its viability, and compare the outcomes in early presentation vs late presentation. Methodology: This was a retrospective study; hence, clinical profiles of all patients during the past seven years were reviewed for those presenting with AULI. Data on anticoagulation were collected, imaging and operative procedures were extracted. All statistical analyses were performed using SPSS 11.0 for Windows. Results: In our study, 25 (42.4%) patients were included due to native arterial thrombosis, 11 (18.6%) due to embolic disease, and the same percentage due to exposure to a high-altitude area (HAA) (more than 9000 feet). 4 (6.8%) patients had thoracic outlet syndrome and cervical rib, and 5 (8.5%) had hypercoagulable disorder. Our study population was younger with a mean of 44.9 years with an SD of 13, and the majority were male (5 out of 59 were female). 16 were active smokers, and 2 were former smokers. The left upper limb incidence was 59% (n = 35), and the right upper limb was 41% (n = 24). In our study, the most common site was the brachial artery 53% (26 out of 49) and axillary artery 35% (17 out of 49) when iatrogenic, traumatic, and thoracic outlet syndromes are excluded. Out of the 59 patients, 39 patients had undergone color Doppler flow imaging of the affected limb and 30 patients had undergone CT angiography of the arch and the limb. Two patients presented with gangrene to the forearm, and 12 patients underwent Colour doppler flow imaging (CDFI) before they presented to our center. In our study, 37% of the patients presented within 48 hours of the onset of symptoms, out of which above-elbow amputation was done in only 1 patient, that is, 4.5%, and 24% of the patients presented within an 8–14-day period, among which one patient (11%) had undergone above-elbow amputation and 22% of the patients presented after 14 days, in which there were 2 above-elbow-amputation patients (15%) with a statistically non-significant P value of 0.5. A total of 45 patients were managed with anticoagulation. A detailed discussion on the treatment outcome of each case has been presented in the article. Conclusion: CT angiography, when available, is a well-accepted first-line investigation for AULI. When we compare AULI with lower-limb ischemia, collateral circulation conservative management is also an option, provided that it is not associated with tissue loss. AULI like lower-limb ischemia has better limb salvage when diagnosed and intervened early.

An unusual presentation of a rare disease: acute upper limb ischemia as the presenting symptom of Whipple’s Endocarditis, a case report

BackgroundWhipple's disease is known to cause multiple varied systemic symptoms, and is a well-documented cause of culture-negative endocarditis. Endocarditis secondary to Whipple disease, however, has rarely been known to present primarily as a cause of acute limb ischemia. We describe such a case here.Case presentationA previously healthy 40 year old man presented to the emergency department with acute-onset right arm paresthesias. On exam, he was found to be tachycardic with a VI/VI systolic ejection murmur. He was diagnosed with critical limb ischemia and severe aortic regurgitation, and echocardiography showed a large mass on his bicuspid aortic valve. Thrombectomy was performed urgently, with aortic valve repair the following day. As blood cultures and valvular tissue culture remained unrevealing, the patient remained on empiric vancomycin and ceftriaxone for culture-negative endocarditis. 16 s rRNA nucleic acid amplification testing (NAAT) of his formalin-fixed, paraffin-embedded valvular tissue detected T. whipplei, after which the patient was transitioned to ceftriaxone and trimethoprim-sulfamethoxazole for a year of therapy. He continues to do clinically well.ConclusionsWe report an unusual presentation of Whipple endocarditis as an acute upper limb ischemia, absent other classic symptoms of Whipple's disease, and with diagnosis made by 16 s rRNA NAAT of valvular tissue in the setting of culture-negative endocarditis.

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

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.

Evolution and transformation of JVS-CIT

Evolution and transformation of JVS-CIT

A Case of Brachial Artery Thrombosis Caused by Massage of an Occluded Arteriovenous Graft

Background: Acute upper limb ischemia (AULI) is a potential complication associated with massages of occluded vascular accesses in patients undergoing hemodialysis. Pharmacological thrombolysis, endovascular intervention and surgical intervention are possible treatment options. Deciding the appropriate treatment strategy is still a controversial issue. Case Presentation: The patient was a 43-year-old woman with renal failure who underwent hemodialysis and peritoneal dialysis. She was found to have an arteriovenous graft (AVG) thrombosis at the start of a hemodialysis session. She underwent massage of the vascular access, and immediately after the massage, she reported pain and cyanosis in her right-hand fingers and was referred to our hospital. Duplex ultrasonography revealed a large number of thrombi in the brachial, radial and ulnar arteries. AULI due to brachial artery thrombosis was diagnosed and surgical intervention was performed on the same day. The vascular wall of the forearm artery was incised vertically against the running vessel and thrombi around the bifurcation of the radial and ulnar arteries were removed. Angiography guided-surgical intervention was performed and improvement in blood flow was achieved. The patient was discharged on the second day after the operation. Conclusion: Surgical intervention has been reported as an effective treatment of AULI due to brachial artery thrombosis after massage of an occluded vascular access.

Overview on Causes and Management of Upper Extremity Ischemia- A Review

Acute upper limb ischemia (AULI) occurs less often than acute lower limb ischemia, contributing for even less than 5% of all limb ischemia instances. It is known to be rare vascular emergency with serious long-term effects if not treated promptly. Timely detection and localization of the arterial occlusion are critical for effective revascularization and limb salvage. Surgical procedure, most commonly embolectomy, has become the standard of care for embolic or thrombotic AULI. Vascular repair is synonymous with morbidity and death, which can be avoided in some circumstances. Nonsurgical options such as endovascular procedures, thrombolytic agents, and anticoagulation therapy continue to advance, but their function in upper extremity ischemia remains unclear. In this Review, we discuss causes and management of acute upper extremity ischemia. The paper concluded that longer symptoms mean greater likelihood of functional sequelae. Surgical management is the most commonly used and best treatment. It is also possible that conservative management is being underreported. The prognosis of upper extremity ischemia is related to prompt and appropriate treatment and is predictable based on initial serum LDH levels.

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

BackgroundAcute 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.MethodsPatients 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.ResultsSixteen 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.ConclusionGood 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.

Concomitant Acute Ischemic Stroke and Upper Extremity Arterial Occlusion: Feasibility of Mechanical Thrombectomy of the Upper Limb Using Neurointerventional Devices and Techniques.

Background: Concomitant acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), and acute upper extremity arterial occlusion causing upper limb ischemia (ULI) is a rarely observed coincidence. The first-line treatment for AIS is mechanical thrombectomy (MT), with or without additional intravenous thrombolysis, while there are different pharmacological, surgical and endovascular treatment options for an acute occlusion of the UL arteries. Here, we describe the practicability, efficacy and safety of neurointerventional devices and techniques for MT of upper extremity arterial occlusions. Materials and Methods: A retrospective analysis of prospectively collected patient databases from four neurovascular centers was performed. Clinical and imaging data, as well as procedural parameters, were assessed. Results: Seven out of 6138 patients (incidence: 0.11%) presenting with an AIS due to the occlusion of craniocervical arteries requiring MT and a concomitant occlusion of the brachial (4/7), axillary (2/7), or ulnar (1/7) artery causing acute ULI were identified. Craniocervical MT was technically successful in all cases. Subsequent MT of the upper limb was performed using neurointerventional thrombectomy techniques, most frequently stent retriever thrombectomy (in 4/7 cases) and direct aspiration (in 7/7 cases). MT achieved successful recanalization in 6/7 cases, and the UL completely recovered in all six cases. In one case, recanalization was not successful, and the patient still had a marginally threatened extremity after the procedure, which improved after pharmacological therapy. Conclusion: In the rare case of AIS requiring MT and concomitant acute upper extremity arterial occlusion, MT of the UL arteries using neurointerventional devices and techniques is practical, effective, and safe.

Acute Neonatal Upper Limb Ischemia: Topical Vasodilation, Anticoagulation and Physical Therapy-A new option for complete reversal of ischemia

Acute upper limb ischemia in neonates is extremely rare and oftenassociated with disastrous outcomes including digital gangrene, chroniclimb ischemia, sepsis and limb loss. It is usually seen in the contextof intra-arterial catheters in the preterm neonates but it can be alsoseen in cases of difficult or traumatic deliveries as well as in infantswith coagulation deficits but can also be spontaneous with no obviousaetiology. Treatment options include topical vasodilators, systemicanticoagulation and in some instances, surgical intervention. We reportthree cases of acute limb ischemia in preterm neonates in which anew treatment option was introduced. The neonates responded to acombination of topical nitro-glycerine cream, systemic anticoagulationwith heparin and physical light massaging of the area just proximalto the site of reduced flow in the vessel assuming some degree ofvasospasm of the vessel occurs with or without thrombosis.Keywords: neonatal ischemia, management of neonatal ischemia, topicalvasodilators, systemic anticoagulation, massage therapy, surgicalintervention

Acute Upper Limb Ischemia in a Patient with COVID-19 Pneumonia

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is an enveloped RNA beta coronavirus. It is a novel coronavirus responsible for the current global pandemic and poses a critical threat to global health worldwide .

Acute Upper Limb Ischemia after an Accidental Intra-Arterial Antispasmodic Injection on an Anatomical Variant of the Radial Artery: A Case Report and Review of the Literature

Acute Upper Limb Ischemia after an Accidental Intra-Arterial Antispasmodic Injection on an Anatomical Variant of the Radial Artery: A Case Report and Review of the Literature

Ultrasound-guided T2 and T3 paravertebral block versus ultrasound-guided stellate ganglion block in acute upper limb ischemia

Background Accidental intra-arterial injection can cause severe limb ischemia, often resulting in amputation. We reported a number of cases of acute upper limb ischemia with severe pain and ischemia in vascular surgery department for urgent relief of the pain and ischemia. Either ultrasound-guided stellate ganglion block or thoracic paravertebral block was done to protect upper limb from gangrene and amputation. Purpose The aim of the present study is to compare the effect of ultrasound-guided stellate ganglion block with ultrasound-guided thoracic T2 and T3 paravertebral block in relief of pain and ischemia and also to compare the result of the block and complications. Patients and methods Forty American Society of Anaesthesiologists status I–II adult patients 16–60 years of age with acute upper limb ischemia and severe pain were admitted to Vascular Surgery Department of Zagazig University Hospital. They were randomly divided into two groups: group S (n=20) where ultrasound-guided stellate ganglion block was done, and group TPV (n=20), where ultrasound-guided thoracic paravertebral block was done. Both groups received 10 ml bupivacaine (0.25%)+16 mg dexamethasone for relief of the pain and ischemia, and the complications that resulted from the procedure were followed and recorded. Results There was significant decrease in visual analog scale in both groups after the stellate ganglion block and thoracic paravertebral block, with minimal complications with thoracic paravertebral block and relief of pain and ischemia in both groups. Conclusion Thoracic paravertebral block is a good choice in acute upper limb ischemia with rapid relief of the pain and restoration of peripheral perfusion with minimal complications.

A Cohort Study of Upper Critical Limb Ischemia Secondary to Atherosclerotic Occlusive Disease

Introduction - Introduction: upper critical limb ischaemia (UCLI) secondary to atherosclerotic occlusive disease is rare. Accordingly, revascularisation indications and outcomes remain unclear. In this relatively large series, we review our experience in managing this condition. Methods - Patients and Methods: This is a cohort study of patients presenting to a tertiary referral centre with UCLI (rest pain and/or tissue loss) between January 2012 and December 2016. Patients with acute upper limb ischaemia or arm claudication were excluded. All patients underwent full imaging (CT/MR or CO2 angiography). Results - Results: during the study period, 20 male patients with 25 ischaemic limbs and 7 female patients with 8 ischaemic limbs, met the inclusion criteria. Median (range) age was 59 (17-71) years and 44% were smokers. 93% of patients were diabetic and 80% of those had elevated HBA1c. 89% were hypertensive and 52% had concurrent or previous history of lower CLI. In addition, 74% had end-stage renal disease and 41% had haemoglobin levels <110g/l. 78% of patient were on antiplatelets and statins at the time of presentation. In the affected limbs, the distribution of significant arterial occlusive disease was: 15% subclavian, 0% axillary, 9% brachial, 45% ulnar, 58% radial and 73% palmar/digital. 52% of limbs underwent revascularisation (12 via angioplasty and 5 via vein bypass surgery). 21% (7) limbs were deemed non-reconstructible. 9 patients had significant concomitant circulatory failure secondary to cardiac or septic pathologies. These were managed expectantly. 18% of limbs required digit and/or partial palm amputation. None required major amputation. Overall 1 year mortality was 30%, however, mortality was twice as much in the no-intervention group (40% vs. 20%). Conclusion - Conclusion: In our experience, UCLI secondary to diabetic arteriopathy is fast increasing. Characteristically, the disease is infra-cubital with particular affinity to palmar and digital vessels. Although major amputation is rarely required, these patients tend to have significant comorbidities and poor survival.

Acute upper limb ischemia: 30 years’ experience

The OBJECTIVE of the study was to assess the current trends in the surgery of acute upper limb ischemia (AULI). MATERIAL AND METHODS. We performed the comparative analysis of clinical data and treatment results of 261 patients with AULI urgently treated between 2008 and 2018 years (main group) and 162 patients with AULI treated between 1975 and 1985 years (control group). RESULTS. For the past 30 years, there were the growing rate of AULI. In 92.7 % of cases, the main cause of AULI was embolism. The main disease leading to embolism became atrial fibrillation in 80.8 % of cases. For the past decades, there was a significant improvement of treatment results in patients with AULI: complete extremity blood flow supply was achieved in 95 % in main group vs 90.5 % in control group (p&lt;0.05); postoperative mortality rate significantly decreased to 3.5 vs 8.8 % respectively (p&lt;0.05). CONCLUSION. AULI continued to remain the actuality in modern vascular surgery.