MANAGEMENT OF ACUTE NON- TRAUMATIC UPPER LIMB ISCHEMIA Thesis Submitted for Complete Fulfillment of The Master Degree in General Surgery By Ahmed Gamil Mohammed Ali Karmota (M.B.; B.Ch.) Supervisors Prof. Dr. Hussien Kamal Eldin Hussien Professor of General and Vascular Surgery Faculty of Medicine, Cairo University Prof. Dr. Hussien Mahmoud Khairy Professor of General and Vascular Surgery Faculty of Medicine, Cairo University Dr. Ahmed Sayed Mostafa Assistant Prof. of General and Vascular Surgery Faculty of Medicine, Cairo University FACULTY OF MEDICINE CAIRO UNIVERSITY 2012 ii Acknowledgement ACKNOWLEDGEMENT First of all, all gratitude to ALLAH who aided me to bring forth this thesis to light. Peace and blessing upon messenger of Allah and whenever supports him. I would like to express my appreciation and gratitude to all those who helped me in completion of this work. I would like to particularly extend my thanks to Prof. Dr. Hussein Kamal El Din, Professor of General & Vascular Surgery, Faculty of Medicine, Cairo University, for his precious guidance, great encouragement and precious advices. My best appreciation to Prof. Dr. Hussein Mahmoud Khairy Professor of General & Vascular Surgery, Faculty of Medicine, Cairo University, for all his advice, supervision, support and teaching me ethics of surgery before the scientific material also i will never forget his continuous encouragement throughout my residency period. I would like also to express my gratitude to Dr. Ahmed Said Assistant Professor of General & Vascular Surgery, Faculty of Medicine, Cairo University, for her assistance , aid and precious advices in conducting this study. Last but not least, I would like to thank my father and mother and my family for their patience and support without which the completion of this work would not have been possible. Ahmed Gamil Mohammed iii Contents CONTENTS Page . Introduction ……….…………………………………….. 1 . Aim of The Work ................................................................ 3 . Review of Literature …………………………………… 4 o Anatomy of arterial tree of the upper limb …………. 4 o Etiology of acute non traumatic upper limb ischemia……. 16 o Pathophysiology of acute limb ischemia……………… 29 o Diagnosis of acute non traumatic upper limb ischemia… 32 o Management of acute non traumatic upper limb ischemia 42 . Patient and Methods ......................................................... 69 . Results …………………………………………….… 75 . Discussion .......................................................................... 91 . Summary and Conclusions …………………............... 104 . References ……………………………...………............. 107 . Arabic Summary …………………….……………………... iv List of Figures LIST OF FIGURES No. Title Page 1 An incision is made over the scapula, lateral to the 5 insertion of the sternocleidomastoid muscle 2 The anterior scalene is divided carefully, protecting the 6 phrenic nerve which is best performed by passing a sling around it 3 Division of the anterior scalene reveals the subclavian 6 artery and branches 4 After division of the clavicle downwards retraction reveals 7 the distal part of subclavian artery as it crosses the first rib and the upper part of the axillary artery. 5 Anastomosis around the scapula and surgical neck of the 9 humerous 6 This can be exposed throughout the upper arm by incision 10 place along its medial border just behind the biceps muscle 7 For exposure of the bifurcation of the brachial artery an S- 11 shaped incision should be made in the antecubital fossa 8 After division of the bicipital aponeurosis the brachial 11 artery and it bifurcation into radial and ulnar arteries will be seen where they pass between the brachioradialis and flexor muscles. The median nerve and basilica vein can be seen posteromedial to the artery 9 Anastmosis arund the elbow 12 10 Anastmosis around the wrist and arteries of the hand 14 11 The most common sites of arterial embolic occlusions 21 12 Right upper limb acute ischemia showing pallor of the 34 hand and amputated fingers 13 Time to presentation in relation to etiology 37 14 CT angiography of right upper limb showing subclavian 40 artery aneurysm and axillary artery occlusion 15 Angiography of left upper limb showing axillary artery 41 occlusion 16 Axillobrachial bypass. Shown is the completed bypass, 53 with the greater saphenous vein tunneled subcutaneously 17 Brachial embolectomy. Shown are (a) a lazy S skin 56 v List of Figures No. Title Page incision and (b) the main nerves and vessels exposed 18 Intra-operative photograph. The anterior compartment has 61 been incised, revealing a pale, oedematous but viable biceps brachi 19 Angiogram of right upper limb showing stent in the right 64 subclavian artery 20 showing the scheme of management of acute non 72 traumatic upper limb ischemia 21 According to limb affection 75 22 Angiography showing stent in the left subclavian artery 76 23 Percentage of male & female patients 77 24 Risk factors for upper limb ischemia 78 25 sites of occlusion 81 26 Shows aetiology of ischemia of the lesions 82 27 Showing management and outcome of our study 84 population. 28 Left upper limb befor intervention showing delayed 88 presentation with fixed color changes and gangrene 29 (a) leftt thrombotic upper limb ischemia showing color 89 changes in index finger (b) left upper limb thrombotic ischemia after conservative treatment 30 CT angiography of left upper limb showing brachial artery 90 occlusion 31 Intraoperative photograph showing axillo-axillary bypass 90 with synthetic graft vi List of Tables LIST OF TABLES No. Title Page 1 Differentiation of Embolism from Thrombosis 16 2 Clinical Categorization of ALI Findings Doppler 36 Signal 3 Clinical Categorization of ALI Findings Doppler 79 Signal 4a,b Clinical presentation of the patients 80 5 Sites of occlusion 81 6 Shows the distribution of patients among the different 83 times of delay 7 1-month Limb salvage in relation to delay 86 8 1-month Limb salvage in relation to class of ischemia 86 9 Relation between delay and class of presentation 86 vii Abbreviations ABBREVIATIONS AF Atrial fibrillation ALI Acute limb ischemia aTOS Arterial thoracic outlet syndrome BA Brachial artery BP Blood pressure CBC Complete blood count CK Creatin phosphokinase CRP C-reactive protien CTA Computed tomographic angiography ECG Electrocardiogram ESR Erythrocyte sidementation rate Fr French H Hour IHD Ischemic heart disease INR International normalized ratio IVC Inferior vaena cava LDH Lactate dehydrogenase LDL low-density lipoproteins LL Lower limb MI Myocardial infarction MI Myocardial infarction MRA Magnetic resonance angiography PMT Percutaneous mechanical thrombectomy PTA Percautanius transluminal angioplasty RBS Random blood sugar RHD Rheumatic heart disease RS Raynaud's Syndrome SA Subclavian artery TAO Thromboangiitis Obliterans TOEC Transesophageal echocardiography TOS thoracic outlet syndrome UL Upper limb vTOS Vascular thoracic outlet syndrome viii Abstract ABSTRACT Acute non-traumatic upper limb ischemia is mainly due to acute embolic or thrombotic ischemia, differentiation between both is very important as management is different as regard embolectomy, anticoagulation, thrombolytic therapy, bypass surgery or endovascular interventions, different method of diagnosis is available clinically (history and examination), duplex or angiography. The aim of this study is to identify the best method of diagnosis and management. Key Words: Acute upper limb ischemia, Embolic, Thrombotic, Duplex, Embolectomy, Anticoagulation Endovascular Bypass ix Introduction INTRODUCTION Upper limb ischemia is an uncommon entity which presents less commonly as compared to lower limb ischemia and has a wide range of aetiologies and controversies in preoperative investigation and management. The most common presenting symptoms of acute upper limb ischemia are numbness, weakness, pain, pallor and pulslessness. Less than 2% present with rest pain, gangrene or ulcer (Quraishy et al., 1992). Although the incidence of upper limb loss is less as compared to lower limb, it can result in severe functional impairment and disability if there should be any delay in diagnosis and treatment. The single most common etiology is thromboembolic event secondary to atherosclerosis followed by trauma. Nevertheless, differential diagnosis such as arteritis, thoracic outlet obstruction and aneurysms need to be considered (Bang and Nalachandran, 2009). Available treatment options for acute upper limb ischemia include thromboembolectomy, thrombolysis, administration of heparin, percutaneous transluminal angioplasty and bypass surgery. Amputation and loss of function of upper limb is rare (Puma et al., 2005). Treatment of acute non traumatic upper limb ischemia is a difficult problem and no technique being suitable for all patients. The presence of radial pulsation after embolectomy is often 1 Introduction regarded as important but it is possible to get a good functional recovery without return of radial pulse (Still Investigators, 1994). Numerous follow up studies have been published regarding the long term effect of embolectomy in lower limb extremities, only few reports on upper limb extremities and most of them present short term outcome (Magishi et al., 2008). 2 Aim of the Work AIM OF WORK 1. To detect the incidence of acute non traumatic upper limb ischemia as compared to acute non traumatic lower limb ischemia. 2. Identify the prevelance of different causes of acute non traumatic upper limb ischemia. 3. Describe the spectrum of presentations of acute non traumatic