Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 31 (2013) 1719.e1-1719.e4

Short series of upper limb Acute arterial occlusions in 4 different etiologies and review of literature

Abstract

Upper limb acute arterial occlusions are uncommon, and when compared with lower limb occlusions, only a few cases have been reported. Although atrial fibrillation is the most common cause, many conditions may lead to ischemia. In this article, 8 cases of upper limb arterial ischemia due to 4 different etiologies were reported (7 brachial, 1 axillary), and the literature was reviewed.

Limb ischemia results from failure of Blood supply to meet tissue oxygen and nutrient requirements. As time proceeds, cell death and irreversible tissue damage occur, and irReversible changes are seen in peripheral nerves and skeletal muscle within 6 hours. Acute limb ischemia (AULI) is a serious emergency requiring immediate therapy for limb salvage. Acute limb ischemia is not always as limb- threatening as those in the leg, and thromboembolectomy is not always necessary for limb salvage. Because of well-developed collateral circulation around the shoulder and elbow, these areas usually are much more tolerant of ischemia; thus, in Clinical cases, occlusions around the elbow are more common. The development of Ischemic changes around shoulder and elbow depends on the collateral blood supply [1-3].

Eight patients who presented to Ankara Guven Hospital and TOBB- ETU Hospital, Ankara, Turkey with upper limb ischemia from 2005 to 2012 were reported. The mean duration of AULI was 2.2 hours (range, 1-4 hours). Six of them have significant medical backgrounds of ischemic heart disease, hypertension, hyperlipidemia, and diabetes mellitus. One patient had myocardial infarction 2 weeks ago, and 1 had a transient ischemic attack a year ago.

Five patients had atrial fibrillation with concomitant diseases; 81- and 78-year-old men and an 85-year-old woman with history of hypertension and ischemic heart disease, a 71-year-old man with history of chronic obstructive pulmonary disease, and a 75-year-old man under nontherapeutic level treatment of warfarin were admitted to the emergency unit with the complaints of sudden pain around the elbow and discoloration of forearm. Doppler ultrasonographies of the Brachial artery revealed thrombi; then embolectomies were per- formed. Etiologically, these 5 patients were considered cardioembolic. One patient had myocardial infarction 2 weeks ago, and 1 had a transient ischemic attack a year ago.

A 78-year-old woman with a history of hypertension and atrial fibrillation was admitted to the emergency unit. She had gradually elevated pain on the elbow for 6 hours and discoloration of forearm for 2 hours. Doppler ultrasonography revealed thrombi in the last section of brachial artery (2 cm length), bifurcation, and both proximal radial and ulnar artery (2 cm length). Probably, the patient had initially an incomplete brachial artery embolism; then the

thrombosis of brachial, ulnar, and Radial artery was included to this condition. Etiologically, the patient was considered cardioembolic and superimposed thrombosis.

A 38-year-old woman with a history of brachial arterial cannula- tion for arterial blood gas analysis was admitted to the emergency unit with right upper extremity pain, pallor, and coldness. Doppler ultrasonography of the brachial artery revealed a 3-cm segment thrombus above the bifurcation. There was no blood flow in distal section of forearm. Etiologically, the patient was considered as a catheter-induced thrombosis.

A 34-year-old man was admitted to the emergency unit due to a fall from a height of about 6 m. On physical examination, the patient was unconscious and had open wound with multiple tendon, muscle injuries, and open fracture of humerus. Because of the pulselessness and discoloration of arm, crash injury or rupture of axillary artery was initially thought. Cerebral hemorrhage and edema were detected on performed tomographic scans as a concomitant condition. Then the patient underwent emergent surgical operation for limb salvage. In the operating room, the integrity of the axillary artery was normal; instead, at the third part, 4-cm segment thrombus formation was detected. Thrombect- omy and axillary bypass operation were performed. Because of orthopedic and neurosurgical problems, patient was discharged after the 26th day of follow-up. The patient was identified with direct trauma-induced thrombosis.

Patients with brachial artery occlusions had embolectomy done with Fogarty balloon, and the average time from presentation to surgery ranged from 2 to 6 hours.

The patients experienced total resolution of symptoms, and there was no sequela.

This study was a review of all data published in English on AULI. Because there are no randomized clinical or prospective studies, all retrospective series were reviewed. Medline database was searched and followed by a secondary hand search of the article reference lists. We excluded patients who developed upper limb ischemia as a complication secondary to arteriovenous fistula creation for hemodi- alysis and inflammatory vasculitis and Reynaud’s disease because they were beyond the scope of this research.

Acute limb ischemia is less common than acute lower limb ischemia; the incidence has been reported as 0.86 to 1.3 cases per 100000 per year [4]. Patients tend to be older, with mean age of 74 years. Embolism is the most common cause (74% of the cases), mostly observed on the right arm. Symptoms of the disease increase with age and are 2 to 4 times more common in men. Brachial artery catheterization injury is the most common cause of direct arterial injury and iatrogenic ones with 1% of complication rate [2,3].

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Diagnosis of AULI is based on a Detailed history and physical examination, and patients have 1 or more of the 6 “P” findings: pain, pallor, polar (for cold), pulselessness, paresthesias, and paralysis. Most of the time, pain alone is the earliest symptom of ischemia. Duration and location of the arterial blockage, the amount of collateral flow, and the previous health of the involved limb affect the extent of injury. delayed treatment of upper limb occlusions has an 8% potential risk for amputation and residual functional impairment [5,6].

Many conditions may be the reason of ischemia due to thrombosis and emboli or both (Table) [2,3,7-9]. The discrimination between thrombosis and embolism may be difficult and it is clinically impossible to determine in 10-15% of cases. Arterial occlusions may occur in a steady artery due to severe arterial stenosis and atherosclerosis. On the other hand, atherosclerotic disease almost never affects the upper limb [2].

Most arterial emboli (85%) originate from the heart. Coexisting atrial fibrillation, often without mitral stenosis, is present in 60% to 75% of patients with peripheral arterial embolic events. Noncardiac sources of embolism include atheroma in the aortic arch, primary subclavian aneurysm, or aneurysm due to extrinsic compression of Thoracic outlet obstruction. Rare sources include the proximal end of an occluded axillofemoral bypass graft arteritis, malignant emboli, fibromuscular dysplasia, old fracture, and chronic trauma.

Embolic ischemia can be diagnosed with the following criteria: sudden clinical presentation, an Embolic source, absence of peripheral atherosclerosis, and removal of discrete “clot” on operation [2]. These criteria were seen in our first 5 cases.

Atheroembolism, very rarely seen in upper extremity, refers to microemboli that are 100 to 200 um in size. It consists of cholesterol, calcium, and platelet aggregates detached from proximal atheroscle- rotic plaques that precipitate to distal end of arteries. The clot may propagate proximally and distally. If unrecognized, recurrent events lead to loss of collateral circulation, progressive symptoms, and extensive tissue infarction.

Recurrent embolism has a poor outcome and high mortality rate, and echocardiography detects intracardiac thrombus or abnormality [10].

Five percent of cases in population studies and 9% to 35% in surgical series are due to thrombosis in AULI. The diagnosis is important because treatment usually requires bypass surgery. Extrinsic compression, particularly at the thoracic outlet by cervical rib or constricting band, can be the cause of occlusion or distal embolism [3,5,6].

Primarily and the most important risk factor is atrial fibrillation, and, secondarily, the other clot-formatting heart diseases (valvular diseases, cardiomyopathies, and myxoma) are seen. Diabetes, hyper- lipidemia, hypertension, hyperhomocysteinemia, and smoking may be considered indirect risk factors for extremity ischemia [10].

Of patients with occlusive arterial disease, 40% to 60% have either coronary or cerebrovascular disease. The severity of peripheral

Table

Etiologies of arterial occlusions

Embolism Atrial fibrillation (cardiomyopathies, valvular, aneurysmatic, myxoma) Atherosclerotic Plaque rupture

Paradoxical embolism

Thrombosis Trauma, fractures, chronic trauma-such as use of crutches Iatrogenic occlusion-catheterization

Atherosclerotic plaque thrombosis

external compression (cervical ribs, thoracic outlet obstruction) Primary subclavian aneurysm

Connective tissue disorders, arteritis Radiation

Thrombosis associated with malignancy or steroid use Diabetes mellitus

Ergotism, vinyl chloride exposure Hypercoagulable states Vasospasm

vascular disease is closely related to the risk of cardiovascular, cerebrovascular, and great vessel disease [11,12].

Physical examination especially pulselessness is the most impor- tant step for the diagnosis. After clinical examination, further investigation of suspected ischemia can be done with segmental blood Pressure measurements, hand Doppler, Doppler ultrasonogra- phy, and arteriography [2,6,7,13]. In laboratory tests, hyperkalemia, metabolic acidosis, elevated Creatinine kinase, myoglobin, lactic acid, and inflammatory markers such as C-reactive protein level are seen according to the size of the injured area. The extent of injury depends on the duration and location of the arterial blockage, the amount of collateral flow, and the previous health of the involved limb [5,7,14]. The Ankle Brachial Index (ABI) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. The ABI test is a popular tool for the noninvasive assessment of lower limb vascular disease. Compared with the arm, lower blood pressure in the leg is an indication of blocked arteries. Studies have shown that the sensitivity of ABI is 90% with a corresponding 98% specificity for detecting hemodynamically significant (serious) stenosis greater than 50% in major leg arteries, defined by angiogram. However, there is no regular

use of ABI in the patients with AULI [15,16].

Haimovici [17] reported the occlusion locations of AULI patients as brachial 61%, axillary 23%, radial 23%, subclavian 11.7%, and ulnar 1.6%. Other authors also have confirmed that the most commonly occluded artery was the brachial. Because of well-developed collateral circulation around the shoulder and elbow, arterial occlusion is much better tolerated [3,5]. Once occluded, the subclavian artery is compensated by its collateral blood supply from the vertebral arteries. The axillary artery also has a collateral supply from the more proximal subclavian branches. Therefore, combined subclavian and axillary occlusion would cause ischemia of the whole arm.

In the brachial area, if the occlusion occurs before the deep brachial artery origin, then the arm becomes ischemic due to lack of collateral supply. Because blood is supplied to superior and inferior ulnar arteries by the deep brachial artery collaterals and rich collateral structure around the antecubital area, clinical picture of occlusions distal to the deep brachial artery is commonly less severe. However, congenital Vascular variations that exist in 20% to 30% of the population may change the clinical state of the patient [18].

There is considerable controversy about aggressive treatment of AULI, especially when the arm appears viable. Urgent involvement of the emergency physician, radiologist, and vascular surgeon is required to confirm the diagnosis and initiate treatment to restore blood flow. The Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival study assessed the prevalence of occlusive arterial disease in high-risk populations-those older than 70 years and those younger 50 years with diabetes or a smoking history-and found the prevalence to be more than 29% [19]. The goals of therapy for acute arterial obstruction are restoration of blood flow, preserva- tion of limb and life, and prevention of recurrent thrombosis or embolism [2,13]. Further management varies from article to article, but most have reported the use of thromboembolectomy as the primary procedure, followed rarely by arterial bypass surgery. The indication of vasoactive drugs, steroids, bypass, endarterectomy, thrombolysis, decompression of the thoracic outlet, and sympathec- tomy by open or endoscopic methods is not well defined.

As a consensus in the literature, immediate Intravenous heparin anticoagulation for lower limb ischemia should be done; however, there is no consensus for the upper limb. At presentation, all patients can be anticoagulated with heparin, unless contraindicated, and referred to a vascular surgical team. Most studies suggest that anticoagulation with heparin followed by lifelong Warfarin therapy should be routine. Anticoagulation not only reduces the rate of recurrence but also reduces postoperative mortality. On the other hand, Freund et al [20] found no difference in the rate of limb salvage whether heparin was given or not before the operation. In our series,

S. Coskun et al. / American Journal of Emergency Medicine 31 (2013) 1719.e1-1719.e4 1719.e3

low-molecular-weight heparins were administered to the patients with atrial fibrillation (6 patients).

Since Fogarty et al [21] reported the technique of balloon catheter embolectomy in 1963, arterial embolism is best managed by emergency Fogarty catheter embolectomy in nonatherosclerotic limb. Embolectomy can be performed through a single arteriotomy, and transverse incision in the brachial artery is preferred to prevent narrowing. Most commonly, antecubital fossa incision to midbrachial and axillary incision are preferred, and therefore, Fogarty catheter could be passed both proximally and distally. More proximal and more distal emboli are more difficult to treat. The axillary artery approach can be done from the upper third of the arm and the subclavian via the axillary fossa, and palmar arch embolectomy can be performed for more distal emboli [7].

Administration of thrombolytic use for lower limb ischemia has taken place in the literature, yet the use of upper limb is unclear, and few studies in the literature report the use of thrombolysis. Generally, peripheral thrombolysis has approximately 5% chance of major hemorrhage and 2% risk of hemorrhagic stroke [22]. Cejna et al [23] found that thrombolysis gave results similar to those of surgery except for distal occlusion. The use of thrombolysis in the upper extremity is more likely to result in hemorrhagic stroke compared with the one used in the lower limb. Lytic therapy should be particularly avoided in the treatment of subclavian artery thrombus because posterior circulation Cerebrovascular events due to vertebral artery embolization are possible [24,25].

Endarterectomy or anatomic or extra-anatomic surgical bypass via grafting with the otogen vein or Dacron graft can be done, but there is limited information in the literature. These procedures can be effective for distal occlusions for selected patients. If the embolic source is a proximal arterial lesion, definitive surgery or angioplasty is required. It can be done either at the same time or later. Satiani [26] suggests fasciotomy to embolectomy patients if the duration of ischemia is more than 48 hours. On the other hand, arm has loose fascial compartments, and compartment syndrome is rare.

No studies used conservative Anticoagulation management as a primary therapy. Despite the common use of conservative manage- ment in practice as an alternative to surgery, there is a remarkable absence of reports of AULI conservative management. It is also possible that conservative management is underreported. This under- reporting not only makes the literature difficult to evaluate but also makes the literature inaccurate. Conservative treatment is usually reserved for patients who are considered not suitable for the invasive treatment in the literature.

Before embolectomy became routine, available treatment includ- ed warming of the arm, chemical vasodilatation, anticoagulation, and stellate ganglion block and surgical sympathectomy, which were used for AULI. Before the Fogarty catheter’s worldwide use, Baird and Lajos

[27] treated 78 patients of AULI conservatively, only 22 of those received any forms of anticoagulation; the remaining 56 received only supportive therapy. Despite that, 68% of patients had a “good” result, 24% had a “fair” outcome with few residual symptoms, and 8% had severely nonfunctioning limbs or required amputation [27].

Currently, Conservative therapy includes anticoagulation with heparin, rehydration, bed rest, and treatment of contributing medical conditions, such as cardiac failure and dysrhythmia. In another recent study, Turner et al [28] used the conservative approach to all suitable patients and reported on a 17-patient series. Only 1 patient necessitated immediate surgery, and surgery was required on 2 patients after a period of watchful waiting.

In patients with non-limb-threatening ischemia, the distinction between embolism and thrombosis determines management. In non- limb-threatening ischemia patients, in situ thrombosis is often exacerbated by emergency surgical intervention, and therefore, initially, nonoperative treatment may be preferred.

Iloprost (Schering, Berlin, Germany), a synthetic prostanoid, has been used as an intravenous infusion to improve digital ischemia and has fewer potentially fatal side effects than thrombolysis [29].

Surgically satisfactory results of acute upper limb ischemia were 91% to 100%, with reported re-occlusion rates of 5% to 9%, an amputation rate of 2%, and a postoperative mortality rate of 6% to 9% after thromboembolectomy. Hernandez-Richter et al [30] reported that upper limb complications were high at 20.3%, persistence of ischemia and re-occlusion of the artery occurred in 8.8%, and amputation in 1.8% of patients.

Mostly, patients have many systemic medical problems, and they are therefore more susceptible to surgical complications. Most studies showed a worse outcome in atherosclerotic occlusion than embolization [31,32]. Inappropriate embolectomy or thrombectomy, late presentation, and failure to restore the radial pulse are associated with high morbidity rate and are strong indicators of poor outcome [2,30]. When the complications occur, preoperative angiography should be performed to identify any residual occlusion. In this situation, treatment options include repeated embolectomy, exposure of the distal radial and ulnar arteries with retrograde embolectomy and flushing, the use of intraoperative thrombolysis, and bypass surgery.

Approximately one-third of all deaths from occlusive arterial disease are secondary to metabolic complications upon revasculari- zation in leg, but there is no study on mortality rate of revascular- ization-induced mortality in AULI [33].

An active approach to the management of AULI must be safe and effective and must also reduce the risk of late disabling symptoms. Follow-up studies are also required to determine the true outcomes of conservative and surgical management policies. Although the published data are very limited, there is a significant incidence of residual disability following conservative treatment of acute ischemia of the arm. Although limb loss and death are less likely outcomes following acute arm than acute leg ischemia, a more active surgical approach in the arm might reduce late sequelae. In case of distinct ischemic limb, immediate surgical revascularization is indicated. In the management of AULI, emergency medicine specialists should actively take part in the process of diagnosis and decision making.

Selcuk Coskun MD Department of Emergency Medicine Ankara Ataturk Training and Research Hospital, Ankara 90 06550, Turkey

E-mail address: [email protected]

Lutfi Soylu MD

Department of General Surgery Division of Vascular Surgery, Ankara Guven Hospital

Ankara, Turkey E-mail address: [email protected]

Pinar Koksal Coskun MD

Department of Cardiovascular Surgery

Ankara TOBB-ETU hospital

Ankara, Turkey E-mail address: [email protected]

Murat Bayazit MD Department of General Surgery Division of Vascular Surgery Ankara Guven Hospital

Ankara, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.06.041

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