Ischemia Of Upper Limb Research Articles

Endovascular Treatment Strategy Using Catheter-Directed Thrombolysis, Percutaneous Aspiration Thromboembolectomy, and Angioplasty for Acute Upper Limb Ischemia.

To evaluate the usefulness and safety of endovascular treatments for acute upper limb ischemia (AULI) by using multiple techniques, and to compare catheter-directed thrombolysis (CDT) and percutaneous aspiration thromboembolectomy (PAT) as initial procedures. The study included 18 patients (4 men and 14 women) with AULI, who underwent a total of 20 sessions of endovascular treatment using various endovascular techniques between January 2005 and April 2016. The patients were initially treated with CDT [n=9, CDT-based group (C-G)], PAT [n=6, PAT-based group (P-G)], or angioplasty (n=3). In case of residual emboli, we performed additional endovascular techniques. We assessed technical success, clinical success, and complications. Additionally, we compared the urokinase dosage between the groups. The mean patient age was 74.4years. Technical and clinical success was obtained in all patients. Among the 18 patients, 1 underwent CDT only, 2 underwent PAT only, 1 underwent angioplasty only, and 14 underwent multiple techniques. Two patients from the C-G experienced major complications (cerebellar hemorrhage 1; pseudo-aneurysm in a branch of the ulnar artery 1). The mean urokinase dosage was lower in the P-G than in the C-G (40,000 vs. 246,667IU; Mann-Whitney U test, P=0.004). Endovascular treatment is effective and safe for AULI. A combination of multiple endovascular techniques is important for successful treatment. PAT is suggested as an initial procedure among endovascular techniques, in terms of a lower dosage of urokinase and a lower complication rate. IV, Case-control studies.

Successful Percutaneous Intervention for Chronic Total Occlusion of Left Subclavian Artery

Introduction: Subclavian artery stenosis is most commonly caused by atherosclerotic disease. Surgical treatment is associated with high morbidity and mortality. Intervention is generally reserved for the management of symptomatic patients who present with upper limb ischemia, Vertebrobasilar symptoms and subclavian steal syndrome. Endovascular stenting is preferred over surgery because of high success rate, less invasive and minimal complications. Case report: Here we report a case of 56-year-old female patient with history of hypertension and diabetes presented with dizziness, vertigo and left arm claudication with use of her left upper extremity since last six months. She was diagnosed as a case of subclavian steal syndrome. Treatment: Patient underwent successful Percutaneous Transluminal Angioplasty (PTA) of the left subclavian artery with marked improvement of symptoms at follow-up. Patient was monitored with Duplex ultrasound of left subclavian artery, measurement of BP and examination of pulse at each visit. Conclusion: PTA is an effective and safe with high success rate, less invasive and minimal complications when compared to surgery for the treatment of symptomatic subclavian artery stenosis. However, regular clinical and duplex ultrasound assessment of subclavian artery is necessary after angioplasty for monitoring restenosis.

True Idiopathic Brachial Artery Aneurysm: A Rare Case of Surgical Emergency

We report a case of true brachial artery aneurysm of idiopathic origin in a 53-year-old man complicated by distal thromboembolism resulting in acute critical upper limb ischemia. True aneurysm of the brachial artery is a very rare condition which may be asymptomatic or rarely present with acute thromboembolic episode. Surgical repair is the mainstay of treatment in these cases.

Pellet Embolization after Subclavian Artery Injury: A Case Report

Acute upper limb ischemia caused by a gunshot penetrating vascular injury and subsequent arterial embolization by foreign body is uncommon in everyday practice and is associated with high morbidity/mortality rates, especially with emergency surgery. We present the case of a 72-year old male who attempted suicide using a gun. A gunshot entry wound was evident in the right upper chest region with no pellet exit wound. Radial pulses were palpable bilaterally. Angiography revealed right subclavian artery direct injury and pellet embolization to the brachial artery. The patient underwent open surgery, with reversed saphenous vein interposition graft to replace subclavian artery defect. A pellet was removed by a separate arteriotomy in the brachial artery. Associated injuries were clavicle-comminuted fracture and subclavian vein injury. The patient remained well 5 months later with no reported complications. In conclusions, the presence of radial pulses alone on clinical exam cannot rule out the presence of a significant vascular injury.

Extrathoracic Surgical Treatment of Subclavian Steal Syndrome

Twelve patients with” subclavian steal syndrome” were studied in 36 months period from June 2013 to June 2016. Their age ranged between 21-55 years with a mean age of 32 years. Female sex represented (7/12, 58.33%). All cases were subjected to complete history taking and clinical examination. They presented with drowsiness and, or fainting after left upper limb exercise. This was associated with manifestations of chronic left upper limb ischemia. Investigations were done for all cases including laboratory investigations, Duplex US, Angiography and CT Angiography. Surgical treatment was done for all cases (7 cases were treated by transcervical subclavian -subclavian bypass graft, 4 cases were treated by left common carotid to left subclavian artery bypass graft and one case by right subclavian to left axillary artery bypass graft). Ringed Gortex graft 8mm was used in all cases. The results of all surgical operations were successful and the symptoms of the brain and left upper limb ischemia disappeared. The graft in one case was occluded after 2½ years due to intimal hyperplasia (the case of right subclavian to left axillary artery bypass graft). Clearance of the graft was done by using Fogarty catheter. All grafts were functioning well and the results were excellent.

LBPS 02–25 THE CARDIOVASCULAR INVOLVEMENT IN HYPEREOSINOPHILIC SYNDROME AMONG FILIPINOS

Objective: Hypereosinophilic syndrome (HES) is a very rare disease (0.5% of autopsy series) affecting the cardiovascular system leading to myocardial damage, heart failure, thrombosis and death. At present, there are only 30 published cases internationally. Given its rarity, it is often discovered on postmortem and the diagnosis is delayed. There is paucity of published data regarding this uncommon entity hence we aim to report 4 cases of Filipino patients with HES focusing on their cardiovascular presentation, work up, management and clinical outcomes. Design and Method: This is a decriptive study reporting 4 cases of HES admitted in 10 years at 2 tertiary institutions in the Philippines. Sampling Method: Convenience Sampling Design. Statistical Analysis: Descriptive Statistics. Results: While HES is an extremely rare myelopoetic disorder, 4 Filipino cases were documented in the Philippines. The cardiovascular system can be involved in various ways. Eosinophilic myocarditis (EM) from eosinophilic infiltration is the more common clinical presentation (75%). EM symptomatology, electrocardiographic, echocardiographic findings and increased cardiac enzymes may mimic acute coronary syndrome, making its diagnosis elusive. There is a robust role of cardiac imaging modalities in the diagnosis as typical imaging findings consistent with myocarditis can be detected. Exhaustive search for other causes of myocarditis should be employed. HES can promote a hypercoagulable state through invasive tissue damage and tissue factor exposure leading to a very rare presentation of acute upper limb ischemia. After exhaustive search for other causes of hypercoagulable state and documentation of persistent eosinophilia, there was dramatic improvement in upper extremity blood flow and resolution of peripheral eosinophilia with corticosteroids. Timely initiation of high-dose corticosteroid and antihistamine therapy improves clinical outcomes without waiting for the final histologic diagnosis. Conclusions: To our knowledge, this is the first Filipino case series, the largest of all international case series, of documented HES and its varied cardiovascular manifestations.

Young Lady with Acute Upper Limb Ischemia due to Cervical Band

Introduction: Acute upper limb ischemia is usually caused by compression of cervical rib on subclavian artery. But in very few cases compression may be caused by cervical band which is not evident in conventional radiography.Results and Discussion: This is a case of a 26 year old lady, housewife, having rudimentary cervical rib, presented with acute left upper limb ischemia due to subclavian artery aneurysm. Peroperatively cervical fibrotic bandwas identified and diagnosed as the cause of subclavian artery aneurysm instead of rudimentary cervical rib. Scalenectomy, excision of the cervical band, excision of the aneurysmsac and arterial reconstruction of the subclavian artery was performed. Her operation was uneventful, postoperative recovery was excellent. She was discharged to home on 4th postoperative day ensuring good distal pulsation of affected limb.Conclusion: Though rare, cervical band is a cause of acute upper limb ischemia. So, we must not forget while diagnosing this type of cases.J Bangladesh Coll Phys Surg 2015; 33(2): 101-104

Critical Upper Limb Ischemia due to Subclavian Artery Compression Caused by Initially Undiagnosed Cervical Rib - A Case Report

True subclavian artery aneurysms are relatively rare events. Thoracic outlet compression is responsible for 75% of those aneurysms. They are formed as a result of compression of subclavian artery, for example a cervical rib. A case of subclavian artery aneurysm secondary to cervical rib in a 35 year old young adult, who presented with a critical ischemia in his dominant right upper limb. Plain x-ray of cervical spine revealed bilateral cervical ribs and duplex study of the both upper limb arteries concluded aneurysmal dilatation of mid-distal subclavian artery of both sides with mural thrombus on the right side, marked distal ischemia in the right upper limb due to occlusive thrombus in the distal arterial tree, normal distal arterial flow in the left upper limb. Although it is a rare lesion, cervical rib leading to thoracic outlet compression should always be included in the differential diagnosis of a critically ischemic limb in young age group. Surgical management should be considered in a patient with subclavian artery aneurysm due to cervical rib to prevent additional embolic events.University Heart Journal Vol. 11, No. 1, January 2015; 48-51

Nonoperative Management of Acute Upper Limb Ischemia.

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. 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. 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. 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.

WCC 2016-112: A case of varied presentation of thrombus

AbstractAntiphospholipid syndrome is a well defined entity that is characterized by spontaneous abortion, thrombocytopenia, and recurrent arterial and venous thromboses. A right atrial thrombus mimicking myxoma with pulmonary thromboembolism in a patient with secondary antiphospholipid syndrome is rare.Herein, we describe the case of a 35 year old woman who was admitted to the hospital with shortness of breath, swelling of both lower limbs. Transthoracic and transesophageal echocardiography showed a right atrial mass suggestive of myxoma, and the patient subsequently underwent surgery. A histologic examination of the mass showed myxoma. In our patient, the preoperative investigations could not differentiate the thrombus from a myxoma, and she was operated in outside hospital. Later she presented with deep vein thrombosis and pulmonary thromboembolism to our hospital and was diagnosed as having secondary antiphospolipid syndrome and the review sides of the right atrial mass showed thrombus. Intracardiac thrombus has been rarely reported as a compication of antiphospholipid syndrome. Case report: In December 2015, a 35 year old woman was admitted to the hospital with swelling of both lower limbs since 15 days, shortness of breath since 15 days. She had a past history of acute left upper limb ischemia in 15/4/2013 for which catheter directed thrombolysis of brachial artery was done with steptokinase, coronary angiogram showed normal coronaries. History of cervical TB lymphadenitis for which she used ATT for 9 months in 2013. History of excision of right atrial myxoma was done on 3/11/15 at outside hospital. Histologic examination showed myxoma. Patient has pallor and bilateral pedal odema on general examination. At admission vitals were stable and systemic examination was normal except for raised jugular venous pressure. ECG showed T inversions in leads V 3-6, II, III, aVF. 2D ECHO showed dilated RA/RV severe TR, moderate PAH, RVSP 50 mm of Hg, TAPSE 1.3, good LV function, mild RV dysfunction, mobile thrombus at the junction of middle hepatic vein & IVC. CTPA showed saddle thrombus in PA extending into RPA, multiple collaterals in anterior & posterior chest wall with non visualisation of part of left subclavian vein.

Endovascular Treatment of Atherosclerotic Iliac Stenosis: Local and Systemic Complications of the Open Brachial Access

The femoral access is the approach of reference for iliac angioplasty. In the current context of an early ambulation and a minimization of in-hospital stay period, the brachial access seems to be an appropriate approach, especially that long and small diameter equipments are available. Furthermore, it is extremely useful in case of inappropriate or unavailable femoral access. The aim of this study was to evaluate the complication risk factors of the brachial approach in the treatment of iliac stenosis. Between January 2012 and December 2013, we performed 281 iliac transluminal angioplasties of which 57 (20%) consecutive left brachial artery accesses were performed in 54 patients. The choice of brachial access was justified in 68% of the cases by an unavailable femoral access, in 29% of the cases by the presence of bilateral iliac lesions, and in 3% of the cases after failure of retrograde femoral approach. The patients were of a male majority (81%) with a mean age of 66±9years. The procedure was performed under local anesthesia in 65% of the cases. No upper limb ischemia or nervous complications had been reported. No cerebrovascular stroke has been identified. One patient presented with dysarthria associated with disorientation without the presence of cerebrovascular ischemia on the computed tomography scan and on the magnetic resonance imaging. There were 3 major hematomas at the brachial access site, which required reoperation; these 3 patients were on dialysis. There was no statistically significant relationship between a complication occurrence and the diameter or length of the introducer. The mean in-hospital stay period was 2days. The procedure was considered successful in 91% of the cases. We reported 5 cases of failure: 4 of which was due to a difficulty in crossing the lesion and 1 due to a very short material. The only significant risk factor of failure was the thrombosis of the iliac axis (odds ratio 23.3, 95% confidence interval 2.5-264.6, P=0.003). The femoral access remains the recommended approach for the treatment of iliac occlusive lesions. However, brachial artery access seems to provide a safe and secure alternative approach for patients when femoral artery access is unavailable. It allows a rapid ambulation and an ambulatory care.

Remote ischemic preconditioning for myocardial protection during single valvular heart surgery: a randomized-controlled trial

Objectives This study aimed to investigate the potential of remote ischemic preconditioning (RIPC) in myocardial protection after elective single valve replacement. Patients and methods Forty patients were randomized to single valve replacement (mitral or aortic) with RIPC or conventional single valve replacement (control). The RIPC protocol was induced by four (5 min) cycles of upper limb ischemia and (5 min) reperfusion using a blood-pressure cuff. Troponin I level at 30 min preoperatively, 3, 6, 12, and 24 h postoperatively, operative time, the duration of cardioplegia, aortic cross-clamping time, cardiopulmonary bypass time, the length of ICU stay, ventilation time, dose of inotropic support requirements, and hemodynamic parameters (central venous pressure, urine output, and mean arterial pressure) were recorded. Results The RIPC group showed a highly significant decrease in serum troponin level at 6, 12, and 24 h postoperatively. There were no significant differences between groups in operative time, duration of cardioplegia, cross-clamping duration, cardiopulmonary bypass time, and hemodynamic parameters. The length of ICU stay and ventilation time showed a nonsignificant decrease in the RIPC group. Total inotropic support in the first 24 h postoperatively showed a highly significant reduction in the RIPC group. Conclusion RIPC reduced the total amount of troponin I significantly postoperatively; also, it decreased the inotropic support needed postoperatively and nonsignificantly improved the ventilation time and ICU stay time.

The Impact of Remote Ischemic Pre-Conditioning on Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography and Angioplasty: A Double-Blind Randomized Clinical Trial.

Background and objectiveContrast-induced nephropathy (CIN) is an acute major complication following intravascular administration of iodinated contrast agents; however, the best approach for preventing CIN is not clear. Remote ischemic pre-conditioning (RIPC) is a new, non-pharmacological method that has been considered for the prevention of CIN following coronary angiography. This study assessed the effects of RIPC with four brief episodes of upper limb ischemia and reperfusion in the prevention of contrast-induced nephropathy (CIN) after coronary angiography and/or angioplasty.MethodsIn this double-blind randomized clinical trial, we enrolled 51 patients with chronic stable angina and non-ST elevation acute coronary syndrome (NSTE.ACS), and they underwent coronary angiography and/or angioplasty. Standard fluid therapy with normal saline was prescribed for all patients before and after the procedure. The patients were divided into two groups, i.e., a study group of patients who had undergone RIPC intervention and a control group of patients who had not undergone RIPC. One hour before the procedure, a sphygmomanometer cuff was placed around one arm and inflated up to 50 mmHg above the systolic pressure for five minutes; then, the cuff was deflated for another five minutes, and this cycle was repeated four times. The patients’ serum creatinine levels were measured at baseline and 48 hours after the procedure, and the incidence of CIN was calculated.ResultsTwenty-one males and 30 females were studied in two groups, i.e., an RIPC intervention group (n = 25) and a control group (n = 26) that were homogenous considering baseline characteristics. No significant difference was observed in the mean level of serum creatinine between the two groups at a post-intervention time of 48 hours (RICP: 1.74 ± 0.70 mg/dL vs. Control: 1.75 ± 0.87 mg/dL; P = 0.64). However, a lower incidence rate of CIN was observed 48 hours after the administration of the contrast medium in the RIPC group, but it was not statistically significant (RIPC: 23.1% vs. Control: 12.0%; P = 0.30).ConclusionIt seems that adequate fluid therapy is still the most effective strategy for preventing CIN and that RIPC might have additional protective effects in very high risk patients, such as those with severe renal insufficiency and heart failure.

Upper Limb Ischemia: Clinical Experiences of Acute and Chronic Upper Limb Ischemia in a Single Center.

BackgroundUpper limb ischemia is less common than lower limb ischemia, and relatively few cases have been reported. This paper reviews the epidemiology, etiology, and clinical characteristics of upper limb ischemia and analyzes the factors affecting functional sequelae after treatment.MethodsThe records of 35 patients with acute and chronic upper limb ischemia who underwent treatment from January 2007 to December 2012 were retrospectively reviewed.ResultsThe median age was 55.03 years, and the number of male patients was 24 (68.6%). The most common etiology was embolism of cardiac origin, followed by thrombosis with secondary trauma, and the brachial artery was the most common location for a lesion causing obstruction. Computed tomography angiography was the first-line diagnostic tool in our center. Twenty-eight operations were performed, and conservative therapy was implemented in seven cases. Five deaths (14.3%) occurred during follow-up. Twenty patients (57.1%) complained of functional sequelae after treatment. Functional sequelae were found to be more likely in patients with a longer duration of symptoms (odds ratio, 1.251; p=0.046) and higher lactate dehydrogenase (LDH) levels (odds ratio, 1.001; p=0.031).ConclusionAn increased duration of symptoms and higher initial serum LDH levels were associated with the more frequent occurrence of functional sequelae. The prognosis of upper limb ischemia is associated with prompt and proper treatment and can also be predicted by initial serum LDH levels.

Management of Acute Upper Extremity Ischemia: Treatment Strategies and Outcome

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.

Ischemic brachial artery entrapment syndrome by supracondylar humeral bony spur.

Medial supracondylar spur from the humerus is a rare cause of neurovascular pain of the upper extremity. The spur typically entraps the brachial artery and median nerve, resulting in compression-related symptoms. In advance stages, compression could lead to endothelial damage and thrombotic occlusion of brachial artery. Spur is also associated with an anomalous higher insertion of the pronator teres muscle, which could result in multilevel entrapment of the brachial artery. We report a patient with acute upper limb ischemia secondary to brachial artery compression and distal embolization from a medial supracondylar spur and anomalous attachment of the pronator teres. The entrapped brachial artery and median nerve were released by resection of the spur and of the anomalous belly of the pronator teres with thrombectomy of brachial artery.

Endoscopic thoracic sympathectomy for upper limb ischemia. A 16 year follow-up in a single center

IntroductionThe aim of our study was to evaluate the long term results of Endoscopic Thoracic Sympathectomy (ETS) in the management of upper limb ischemia (ULI). MethodsWe retrospectively reviewed the records of all consecutive patients who underwent ETS for ULI between January 1994 and May 2009. A standardized questionnaire was used to evaluate the long term success, morbidity and overall patient satisfaction. ResultsThirty-five patients (20 female, mean age 49 years (range 23–79)) underwent bilateral (n = 9) and unilateral (n = 27) ETS procedures, respectively. Six patients had Primary (idiopathic) Raynaud Disease. Twenty-nine patients had upper limb ischemia secondary to systemic disorders (n = 12), embolic disease (n = 10), occlusion of the arteries of the arm (n = 5) or hypothenar hammer syndrome (n = 2). Tissue loss at time of surgery was present in nineteen patients. Short term beneficial effects were reported by 12 patients (63%). Eleven of the 35 patients experienced a total of 13 complications or adverse events, whereof 11 were minor or transient. Limb salvage was unsuccessful in three patients because of major amputations (n = 2) or severe functional impairment (n = 1). Necrotectomies or minor amputations without functional impairment were performed in 9 patients. Medium or long term follow up (mean 98 months (range 18–198) was available in 19 out of 22 living patients(86%). Long term beneficial effects were reported by 10 (53%). Overall patient satisfaction was 56%. Compensatory sweating was experienced by 11 patients (58%). ConclusionAlthough the long term efficacy of ETS in our study was moderate (53%), due to its low invasiveness ETS is a valuable option in the management of ULI.

Epidemiology and pathogenesis of thoracic outlet syndrome

Abstract The superior thoracic aperture is a place particularly vulnerable to the occurrence of tissue conflict and the development of a number of neurovascular changes carrying a risk of upper limb dysfunction. The triggering factor in this case is the pressure on the nerve vascular elements brought about by too large muscles of the chest and neck, clavicle fracture and dislocation of the upper ribs, anomalies in the form of ribs, in the neck, or by apex of the lung tumors. Each anatomical anomaly may be a cause of a number of lesions and lead to the development of the disease. Due to the nature of the oppressed structures, there are two basic groups: neurogenic and vascular. The most common variant giving clinical symptoms is neurogenic thoracic outlet syndrome. In this, the compression ratio, the brachial plexus, and for this reason, the vascular surface of the upper limb dysfunction is often overlooked. However, the vascular variant, and especially arterial sub-variant, is very dangerous because it can give complications even in the form of aneurysms, and even upper limb ischemia. The aim of the study is to present the most common changes in the thoracic outlet causing functional disorders of the upper limb.

Systemic vascular response to brachial arteries crossclamping may prognosticate the outcome of remote ischemic preconditioning

Remote ischemic preconditioning (RIPC) is a recent trend in cardiovascular medicine. From the literature, it may be deduced that physiological changes resulted from repeated episodes of brachial-cuff inflation/deflation during RIPC provoke, in some way, systemic “training” of the whole organism. At the same time, the effectiveness of such a “training” is substantially different in different humans, and the latter remains unclear. We propose the hypothesis as follows: the magnitude of real-time response of cardiovascular system to transient upper limb ischemia serves as a predictive indicator of the organismal sensitivity to RIPC preventive procedure and RIPC clinical efficiency in a particular person. The hypothesized prognosis of the RIPC-induced different resistance to post-ischemic reperfusion injury in different patients is represented in a quantitative manner using dynamic infrared examination of all human limbs simultaneously. With this screening method, it is clearly shown that different cohorts of healthy individuals exhibit different organismal responsiveness to upper limb arterial transient crossclamping. If proven, our hypothesis could have important implications for emergency medicine.

Upper limb ischemic gangrene as a complication of hemodialysis access.

Upper limb ischemia is a well-recognized complication of dialysis access creation but progression to gangrene is uncommon. We report a case of upper limb ischemic gangrene and discuss the lessons learned during the management of this case. Clinicians must be vigilant for this complication and they should be reminded that it requires urgent management to prevent tissue loss.