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Upper Extremity Occlusive Disease: Treatment
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%)
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References
Dennis JW, Frykberg ER, Crump JM. New perspectives on the management of penetrating trauma in proximity to major limb arteries. J Vasc Surg. Jan 1990;11(1):84-92; discussion 92-3. [Medline].
Fonseca C, Abraham D, Ponticos M. Neuronal regulators and vascular dysfunction in Raynaud's phenomenon and systemic sclerosis. Curr Vasc Pharmacol. Jan 2009;7(1):34-9. [Medline].
Durham JR, Yao JS, Pearce WH. Arterial injuries in the thoracic outlet syndrome. J Vasc Surg. Jan 1995;21(1):57-69; discussion 70. [Medline].
Eskandari MK, Yao JST. Occupational Vascular Problems. In: Rutherford RB, ed. Vascular Surgery, 6th ed. Philadelphia, Pa:. WB Saunders;2005, in press.
Halpin DP, Moran KT, Jewell ER. Arm ischemia secondary to giant cell arteritis. Ann Vasc Surg. - Moran KT;2(4):381-4. [Medline].
Kaar G, Broe PJ, Bouchier-Hayes DJ. Upper limb emboli. A review of 55 patients managed surgically. J Cardiovasc Surg (Torino). Mar-Apr 1989;30(2):165-8. [Medline].
Kline RM Jr, Hertzer NR, Beven EG. Surgical treatment of brachial artery injuries after cardiac catheterization. J Vasc Surg. Jul 1990;12(1):20-4. [Medline].
Landry GJ, Edwards JM, McLafferty RB, Taylor LM Jr, Porter JM. Long-term outcome of Raynaud's syndrome in a prospectively analyzed patient cohort. J Vasc Surg. Jan 1996;23(1):76-85; discussion 85-6. [Medline].
McCroskey BL, Moore EE, Pearce WH. Traumatic injuries of the brachial artery. Am J Surg. Dec 1988;156(6):553-5. [Medline].
Mesh CL, McCarthy WJ, Pearce WH. Upper extremity bypass grafting. A 15-year experience. Arch Surg. Jul 1993;128(7):795-801; discussion 801-2. [Medline].
Nomura M, Kida S, Yamashima T. Percutaneous transluminal angioplasty and stent placement for subclavian and brachiocephalic artery stenosis in aortitis syndrome. Cardiovasc Intervent Radiol. Sep-Oct 1999;22(5):427-32. [Medline].
Peterson BG, Resnick SA, Morasch MD. Aortic arch vessel stenting: a single-center experience using cerebral protection. Arch Surg. 2006;141:560-564.
Phipp LH, Scott DJ, Kessel D. Subclavian stents and stent-grafts: cause for concern?. J Endovasc Surg. Aug 1999;6(3):223-6. [Medline].
Rodriguez-Lopez JA, Werner A, Martinez R. Stenting for atherosclerotic occlusive disease of the subclavian artery. Ann Vasc Surg. May 1999;13(3):254-60. [Medline].
Safran MR, Bernstein A, Lesavoy MA. Forearm compartment syndrome following brachial arterial puncture in uremia. Ann Plast Surg. May 1994;32(5):535-8. [Medline].
Yao JST, Flinn WR, McCarthy WJ. Upper extremity revascularization. In: Bergan JJ, Yao JST. Techniques in Arterial Surgery. Philadelphia, Pa:. WB Saunders, Co;1990:328-336.
Ziomek S, Quinones-Baldrich WJ, Busuttil RW. The superiority of synthetic arterial grafts over autologous veins in carotid-subclavian bypass. J Vasc Surg. Jan 1986;3(1):140-5. [Medline].
Further Reading
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
Treatment: Upper Extremity Occlusive Disease