Upper Extremity Occlusive Disease Treatment & Management

• 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.

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

• 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

• 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.

• 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.

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.

• 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%)

• Carotid-subclavian bypass yields 86-100% 5-year patency.
• Subclavian transposition yields 95-100% 5-year patency.
• Upper extremity bypass yields 52% 5-year patency.
• Arterial reconstruction for thoracic outlet yields 90% 5-year patency.
• Zero to 25% of patients with Raynaud disease with negative serology findings develop a connective-tissue disease, and 11-60% of patients with Raynaud disease with positive serology findings develop a connective-tissue disease.

Percutaneous transluminal angioplasty (PTLA), with or without stenting, is used to treat proximal subclavian stenosis. The indications for PTLA of subclavian artery stenosis include vertebrobasilar insufficiency with steal, angina with left internal mammary artery (LIMA) graft, and arm fatigue.

The role of a thoracic or digital artery sympathectomy is controversial in patients with digital gangrene. These patients usually have an underlying connective-tissue disease such as scleroderma; calcinosis, cutis, Raynaud phenomenon, esophageal motility disorder, sclerodactyly, and telangiectasia (components of CREST); or systemic lupus erythematosus (SLE). Either thoracic or digital sympathectomy provides a transient 6-12 months of increased skin perfusion.