Joint Hospital Surgical Grand Round Acute Upper Limb

Joint Hospital Surgical Grand Round. Acute Upper Limb Ischaemia Dr Cheung Wai Hung, Timothy Surgery, Princess Margaret Hospital

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Definition of acute limb ischaemia • Inter-Society Consensus for the Management of Peripheral Arterial Disease 2007 (TASC II) – “……sudden decrease in limb perfusion that causes a potential threat to limb viability …. . ” – “……later than two weeks after the onset of the acute event are considered to have chronic limb ischemia. ” [1] https: //medlicker. com

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Epidemiology • Incidence of 1. 3 per 100, 000 [2] • Relative incidence 15%-18% of lower limb ischaemia [3] • Mortality rate around 12% • Slight female predominance • Mean age is at 70 s • Right upper limb is twice affected as left side [1] http: //s 3. amazonaws. com/libapps/accounts/13182/images/epidemiology. MED. jpg [2] Stonebridge PA, Clason AE, Duncan AJ, Nolan B, Jenkins AM, Ruckley CV. Acute ischaemia of the upper limb compared with acute lower limb ischaemia: a 5 -year review. Br J Surg. 1989; 76: 515 -516.

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Causes • Up to 70% cause as embolism [1] • Up to 70% of embolism is from Cardiac source [1] • Iatrogenic arterial catheterization cause trauma to vessel [1] P. EYERS, J. J. EARNSHAW. Review: Acute non-traumatic Arm Ischaemia. British Journal of Surgery 1998. , 85, 1340 -1346

Common sites for embolic acute upper limb ischaemia (AULI) 11. 7% 23% 61% 23% 1. 6%

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Clinical presentation • Classical 6 Ps • Pain • Pallor • Pulselessness • Poikilothermia • Paresthesia • Paralysis

Examination • Rutherford classification • Classified into 3 categories • Viable, threatened and irreversibly damaged • Assessment of sensory, power and pulse doppler signal

Examination Findings Doppler signal Description/P Sensory loss rognosis Muscle weakness Arterial Venous Not immediately threatened None Audible a. Marginally Salvageable if promptly treated Minimal (fingers) or none None Inaudible Audible b. Immediately Salvageable with immediate revascularizati on More than fingers, associated rest pain Mild, moderate Inaudible Audible III. Irreversible Major tissue Profound, loss or anesthetic permanent nerve damage inevitable Profound, paralysis Inaudible Category I. Viable II. Threatened

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Diagnosis • Mainly by Clinical diagnosis • Doppler USG can provide quick bedside information • Imaging provide further information: • Weigh against urgency of revascularization • CTA, DSA, MRA

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Treatment for embolic AULI • Once clinical diagnosis is made, patient should immediately receive anticoagulation by heparin bolus follow by infusion • Exclusion of contraindications • Recommended by: • 2012 American College of Chest Physicians (ACCP) guideline on antithrombotic therapy for peripheral artery occlusive disease • 2007 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) consensus document on the management of peripheral artery disease (PAD)

Treatment of AULI • Embolism – Conservative – Surgical embolectomy – Endovascular treatment • Thrombosis • Trauma • Fasciotomy maybe needed for compartment syndrome

Conservative management

Conservative management • Pre surgical embolectomy era • Different strategies including: • Anticoagulation • Rehydration, optimize cardiac output, Warming • Vasodilatation, Avoidance of vasopressor • Amputation rate up to 8% • Up to 50% of patient with residue functional loss

Surgical Embolectomy

Surgical embolectomy for AULI • S-shaped incision/ Lazy-S incision at antecubital fossa • medially in the groove in the arm • carried transversely across the elbow crease then inferiorly on the lateral forearm. • Fr 2/3/4 Forgarty catheter pass proximally or distally [1]https: //www. youtube. com/watch? v=wv 6 fw. An. V 7 l. I

Surgical embolectomy • Post procedure back bleeding may not be a reliable guide to distal patency [1] • TASC II recommendation No. 32 states that • “…. Unless there is good evidence that adequate circulation has been restored, intraoperative angiography should be performed to identify any residue occlusion or critical arterial lesions requiring further treatment…. ” [1] Mc kenzie et al, value of intraoperative angiography in arterial embolectomy surgery. Can J Sur 1976: 19: 223 -6

Surgical embolectomy

Surgical embolectomy • Systematic review published in 2016 • Literature search in Embase and Pubmed • 23 retrospective studies were included • No prospective or comparative studies available • Studies were categorized into main groups: – Catheter embolectomy: 13 – Catheter directed thrombolysis: 8 – Anticoagulation and medical therapy: 9

Surgical embolectomy • Overall Limb salvage rate 97. 7% • Functional deficit: – Mild 13 -20% – Severe 3 -5% • Local complications as high 20. 3% • Mortality 5. 6% – Mostly caused by systemic complications e. g. , cardiovascular, cerebralvascular

Routine use intra-operative completion angiography?

Routine use intra-operative completion angiography? • Retrospective study published in 2012 • 100 patient in 18 -year with catheter thromboemloectomy • Divided into 2 groups • Selected use of angiogram (A), N=50 • Routine use of angiogram (B), N=50 • Similar demographics with no significant difference

Routine use intra-operative completion angiography? • Higher rate of extension of procedure (26. 0% vs. 4. 0%, P = 0. 002). • At 24 months after embolectomy, • Lower incidence of re-occlusion (12. 0% vs. 2. 0%, P = 0. 05) • No statistical difference in mortality (P > 0. 05). • No amputation required in both groups

Endovascular treatment

Catheter directed thrombolysis • First line treatment in acute lower limb ischaemia • Can reach locations that were difficult for embolectomy catheter • Thrombolytic agents: • Streptokinase • Urokinase • Recombinant tissue plasminogen activator • Require close monitoring, e. g. , ICU • Post procedure angiogram for reassessment [1] http: //www. cirse. org/index. php? pid=1072

Catheter directed thrombolysis • Well established evidence for acute lower limb ischaemia • Landmark randomized prospective studies, e. g. – Thrombolysis or Peripheral Artery Surgery (TOPAS) trial – Surgery versus Thrombolysis for Ischemia of the Lower Extremity (STILE) trial • However, no large scale comparative studies available for acute upper limb ischaemia

Catheter directed thrombolysis

Catheter directed thrombolysis • Overall Limb salvage rate 96. 5% • No consistent data on functional deficits • Local complications • Increased complications for proximal lesions, e. g. cerebral haemorrhage • No comparison between different thrombolytic agents

Endovascular treatment • Retrospective non randomized studies, published 7/2017 • 18 patients from 1/2005 to 4/2016 • All patients are Grade IIa or IIb • 3 main groups • Catheter directed thrombolysis based (CDT): 9 • Percutaneous aspiration based (PAT): 6 • Angioplasty based: 3 (Subclavian artery or arterial dissection)

Endovascular treatment

Endovascular treatment • Clinical and technical success rate 100% • Amputation and mortality 0% • Major complication 10% • Cerebellar haemorrhage • Ulnar artery pseudoaneurysm • PAT use less thrombolytics than CDT – 40, 000 U Vs 246, 667 U, p = 0. 004 • Combination of endovascular techniques is important

Acute Upper Limb Ischaemia (AULI) • Definition • Epidemiology • Causes and common sites • Clinical presentation and examination • Diagnosis • Treatment • Conclusion

Conclusion - I • AULI is not uncommonly seen in clinical practice • Clinical emergency with possible great functional impact • Lack of guidelines • Prompt recognition & diagnosis with history and physical examination • Weigh against urgency of revascularization for imaging • Anticoagulation should be started if no contraindication

Conclusion - II • Surgical embolectomy is well established treatment • Completion angiography can decrease re-occlusion rate • Endovascular treatment showed promising result and can be used as adjunct therapy • Cardiac workup is warranted as most case is caused by cardio-embolic event

Reference 1. Hernandez-Richter T, Angele MK, Helmberger T, Jauch KW, Lauterjung L, Schildberg FW. Acute ischemia of the upper extremity: long-term results following thrombembolectomy with the Fogarty catheter. Langenbecks Arch Surg. 2001; 386: 261 -266. 2. E. C. James, N. T. Khuri, C. W. Fedde, et al. Upper limb ischemia resulting from arterial thromboembolism Am J Surg, 137 (1979), pp. 739 -744 3. H. Haimovici. Cardiogenic embolism of the upper extremity J Cardiovasc Surg, 23 (1982), p. 233 4. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, TASC II Working Group J Vasc Surg. 2007; 45 Suppl S: S 5. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Alonso-Coello P, Bellmunt S, Mc. Gorrian C, Anand SS, Guzman R, Criqui MH, Akl EA, Olav Vandvik P, Lansberg MG, Guyatt GH, Spencer FA, American College of Chest Physicians Chest. 2012; 141(2 Suppl): e 669 S.

Reference 1. Does routine completion angiogram during embolectomy for acute upper-limb ischemia improve outcomes? Zaraca F 1, Ponzoni A, Sbraga P, Stringari C, Ebner JA, Ebner H. Ann Vasc Surg. 2012 Nov; 26(8): 1064 -70. doi: 10. 1016/j. avsg. 2011. 12. 012. Epub 2012 Jun 26. 2. Schrijver AM, de Borst GJ, Vos JA, et al. Catheter-directed thrombolysis as first line treatment of acute nontraumatic upper extremity ischemia. J Vasc Surg. 2011; 53: 58 S. 3. Nonoperative Management of Acute Upper Limb Ischemia Victor W. Wong 1, Melanie R. Major 1, and James P. Higgins 1 HAND 2016, Vol. 11(2) 131 – 143 4. Systematic review of the operative and non-operative management of acute upper limb ischemia E. Jane H. Turner. Ph. D Alexander. Loh. FRCS Adam. Howard. FRCS Journal of Vascular Nursing Volume 30, Issue 3, September 2012, Pages 71 -76 5. Mc kenzie et al, value of intraoperative angiography in arterial embolectomy surgery. Can J Sur 1976: 19: 223 -6

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