eMedicine Specialties > Vascular Surgery > Medical Topics

Upper Extremity Occlusive Disease: Treatment

Author: Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Coauthor(s): James S T Yao, MD, PhD, Emeritus Professor of Surgery, Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine; William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
Contributor Information and Disclosures

Updated: Oct 30, 2009

Treatment

Medical Therapy

  • Long-term warfarin anticoagulation is recommended in patients with peripheral emboli from a cardiac source. An international normalized ratio (INR) of 2-3 is recommended.
  • For emboli off the ascending aorta, aspirin or clopidogrel may be used. In rare cases, low-dose aspirin has been used with warfarin.
  • Nifedipine (10 mg PO tid) is used in patients with vasospastic disease of the hand. If this is not tolerated, prazosin at low dose may be tried. A third-line drug with some effectiveness is hydralazine.
  • Lifestyle changes are essential. Warm gloves must be worn, and the skin must be protected from drying and fissuring. Cold avoidance may require moving to a warm climate and avoidance of significantly chilled or air-conditioned environments. Avoidance of vibration trauma from work or hobbies may be necessary.
  • In patients with Takayasu arteritis or giant cell arteritis, prednisone is the first-line agent. Immunosuppression with methotrexate or cyclophosphamide (Cytoxan) may be necessary.
  • Risk-factor modification and aspirin are essential for the treatment of atherosclerotic occlusion. Smoking cessation is mandatory, particularly in patients with Buerger syndrome. Total cholesterol levels should be reduced to below 200 mg/dL, and the low-density lipoproteins (LDL) levels should be 100 mg/dL or less.

Surgical Therapy

  • Vein or prosthetic bypass
  • Percutaneous balloon angioplasty and stenting
  • Resection of aneurysm
  • Removal of first rib or cervical rib
  • Cervical sympathectomy

Preoperative Details

  • Standard preanesthesia evaluation of a chest radiograph (if patient has chest symptoms), ECG, cardiac evaluation (if cardiac history or examination findings are abnormal), CBC count, and chemistry panel
  • Prophylactic antibiotics
  • Ultrasound mapping to delineate available saphenous or other veins to be used for bypass

Intraoperative Details

  • Carotid subclavian or carotid transposition: Incision is low transverse cervical. Prosthetic bypass is preferred. Complications include lymphocele, Horner syndrome, and phrenic nerve injury.
  • Balloon angioplasty and stenting: These are used via either a retrograde or antegrade approach.
  • Subclavian artery aneurysm resection and removal of cervical rib for thoracic outlet: Incisions are supraclavicular and infraclavicular. Avoid brachial plexus injury. Rib resection is facilitated following division of the artery. Management of distal emboli is difficult. Complications include lymphocele, Horner syndrome, and phrenic nerve injury.
  • Peripheral artery surgery: For the axillary artery, exposure is through a longitudinal incision. Ulnar, median, and musculocutaneous nerve injuries are possible.
  • Brachial artery: It is exposed through an S incision. Median nerve injury is possible.
  • Embolectomy: Embolectomy should be avoided over distension of balloon catheter. Patch brachial and small axillary arteries.

Postoperative Details

  • Monitor distal circulation with frequent pulse examination, with or without Doppler pressures.
  • Monitor for bleeding and hematoma formation.
  • Document neurologic function by testing median, ulnar, and radial nerve function.
  • Be aware that forearm compartment syndrome can occur.
  • Monitor ECG to rule out perioperative myocardial infarction or ischemia.

Follow-up

The patient is seen at 2 weeks for wound check, suture removal, or both. Repeat upper extremity blood flow tests are performed every 3 months for the first year, then annually thereafter. Review the patient's control of risk factors, including smoking.

Complications

  • Bleeding (1%)
  • Hematoma (1%)
  • Phrenic or recurrent nerve injury (2%)
  • Graft occlusion (1-2%)
  • Wound infection (1%)
  • Brachial plexus or peripheral nerve injury (1%)
  • Myocardial infarction (<1%)
  • Stroke (<1%)
  • Death (<1%)

More on Upper Extremity Occlusive Disease

Overview: Upper Extremity Occlusive Disease
Workup: Upper Extremity Occlusive Disease
Treatment: Upper Extremity Occlusive Disease
Follow-up: Upper Extremity Occlusive Disease
Multimedia: Upper Extremity Occlusive Disease
References
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References

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Further Reading

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Keywords

upper extremity occlusive disease, upper extremity arterial disease, atherosclerosis, arteritis, fibromuscular dysplasia, Raynaud syndrome, cold sensitivity, Raynaud disease, subclavian artery stenosis, Takayasu arteritis, subclavian artery disease

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Contributor Information and Disclosures

Author

Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Mark K Eskandari, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, International Society of Endovascular Specialists, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Interventional Radiology, Society of University Surgeons, and Western Surgical Association
Disclosure: Terumo Consulting fee Consulting; W. L. Gore & Associates Consulting fee Consulting; Abbott Vascular Consulting fee Consulting; Cordis Consulting fee Consulting; Boston Scientific Consulting fee Consulting

Coauthor(s)

James S T Yao, MD, PhD, Emeritus Professor of Surgery, Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine
James S T Yao, MD, PhD is a member of the following medical societies: American College of Surgeons, American Congress of Rehabilitation Medicine, American Heart Association, American Medical Association, American Surgical Association, American Venous Forum, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, Illinois State Medical Society, Midwest Surgical Association, Society for Vascular Surgery, Society of University Surgeons, Stroke Council of the American Heart Association, and Western Surgical Association
Disclosure: Nothing to disclose.

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Lawrence Kaufman, MD, Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine
Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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