1. UPPER LIMB ISCHEMIA
DR SAFIA ZAHIR

2. CASE 1
Sughran bb w/o
Muhammad Aslam
45/F , a housewife ,
resident of faisalabad
presented in
emergency

3. PRESENTATION
• Severe pain in right hand-3days
• Numbness , coldness and discoloration of
right hand and blackening till the wrist
• No h/o intermittent claudication
• No h/o direct trauma
• H/o of DM -7yrs which is contolled by diet
and oral hypoglycemic agents

4. EXAMINATION
Discoloration or blackening of right hand till the wrist
severe tenderness
Absent brachial, radial, ulnar pulses as compared to left
Parasthesia
Capillary refill delayed
No palpable mass or soft tissue swelling over right upper
limb
No ulcer
Neurological examination unremarkable

5. INVESTIGATION
Baselines
CBC- hb-9.2
wbc-17.4
platelets-288
Cholestrol-275
Triglycerides-619
Echocardiography shows normal sized left ventricle with
overall mild left ventricular systolic dysfunction. Segmental
wall motion analysis shows hypokinesia of distal half of IVS ,
apex and apical segments of anterior wall
No evidence of clot, EF: 45%
Other baselines were un remarkable

6. • Doppler studies shows clacification of arterial
walls in brachial artery just above the elbow
and lower down in radial and ulnar artery
• On color doppler –gradual damping of flow
from midpoint of brachial artery and absent
flow just above the elbow, in radial and ulnar
arteries

7. • CT angiography of
right upper limb
shows normal outlining
of axillary ,brachial upto
midlevel of arm beyond
this brachial artery is
thrombosed. Radial and
ulnar arteries are not
outlined by contrast rest
of forearm is supplied by
collateral beyond the
level of thrombosis of
brachial artery

9. CASE 2
• Asmat bb w/o Altaf
hussain 40y/F, a
housewife resident of
sialkot presented in
outdoor

10. PRESENTATION
• Pain in right upper limb-1 month
• Progressive blackening of right ring , middle
finger-1month
• Numbness
• h/o intermittent claudication
• h/o DM-3months

11. • Gangrene of distal ring
finger with progressive
blackening if distal
middle finger
• Mild tender
• Absent radial,ulnar, and
brachial pulses as
compared to left
• Capillary refill delayed

12. • Baselines were un remarkable
• Fasting lipid profile-
triglycerides-188(80-150)
cholestrol-148(<200)
T.cholestrol/HDL.cholestrol:5.9(<5.0)
Echocardiography was normal with no
evidence of clot
EF:65%

13. • CT angiography :
normal aortic arch ,
trifurcation , right
subclavian , axillary artery.
Right brachial artery is
normal in upper third, mid
segment is small caliber
with total occlusion
distally. Right radial and
ulnar arteries are not
visualized

14. UPPER LIMB ISCHEMIA
• Is far more uncommon than lower limb ischemia
– Upper extremity has good collateral circulation and low rate of
atherosclerosis
• Responsible for ~15% of vascular procedures for ischemic
limbs
• Of all embolization sites, upper extremity cases accounts for
only 8%
• Functional limb impairment occurs in ¾ of cases if left
untreated
• <5% all extremity ischaemia
• Small vessel disease involving palmar and digital arteries –
majority
• <10% of upper-extremity arterial occulsive disease at large
vessel

15. Chronic limb ischemia
• Small vessel disease/distal arterial disease
-Raynaund’s syndrome
-Connective tissue disease: scleroderma
-Buergers disease
-Ischemia related to occupational injury
repeated trauma to digital arteries
vibration injury
hypothenar hammer syndrome
-Hemotological conditions
-Calciphylaxis: renal failure ,diabetes

16. • Large vessel /proximal disease
-Artherosclerosis
-Aneurysms
-Artheritis : takayasu artheritis,giant cell
artheritis
-Arterial thoracic outlet syndrome

17. Acute upper limb ischemia
• Main causes of upper limb ischemia:
– Embolic occlusion
– Acute in situ thrombosis(acute on chronic occlusion)
– Traumatic injuries
– Aortic dissection
– Atherosclerosis and chronic limb ischemia
– Subclavian steal s/o
– Thoracic outlet s/o
– Iatrogenic causes

18. • Emboli tend to lodge at bifurcation
• 1/2 impacted in brachial artery
• 1/3 impacted in axillary artery
• Rarely ulnar and radial arteries
• 65-80% arise from thrombus in the heart
– 2/3 related to AF, 1/3 due to mural thrombus in MI
• Others due to proximal arteries atherosclerotic
plaques, aneurysm, site of surgery, tumour and
trauma
– Arterial emboli to the arm
Journal of the Royal College of surgeons of Edinburgh 1991; 36: 83-5
Vohra R, Lieberman DP

19. • Classification of acute limb ischemia
(according to V. Savelyev )
Ia degrees — Sensation of numbness, coolness, paresthesia
Ib degrees — Pain
IIa degrees — Paresis
IIb degrees — Plegia
IIIa degrees — Subfascial muscular edema
IIIb degrees — Partial muscular contracture
IIIc degrees — Total muscular contracture

23. • Diagnostic studies:
-plethesmography and segmental pressure
-duplex ultrasonography
-digital pulse volume recordings
- CT angiography
-MR angiography
-selective arteriogram

26. Treatment flow plan for acute upper
limb ischaemia
Hx, medical,
occupational/sport
, drug, P/E,
Doppler
Radial and ulnar
pulse -ve
OT
Angiogram/CT
angiogram
Acute on chronic
causes/ proximal
lesion
OT +/- medical
treatment
OT
Radial and ulnar
pulse +ve
Small arterial
lesions
Workup +
medical
treatments

27. Management
• For limb-threatening ischemia:
– Emergency Fogarty catheter embolectomy
– +/- vascular bypass grafting if in situ thrombosis as
cause of ischemia
– If above measures fail, then primary amputation

28. • Tactics of surgical treatment of sharp arterial impassability.
• At embolismes.
• - embolectomy - can be deferred at 24 o'clock.
• IА - - "-
• IB - - " - - emergency.
• IIА - - "-
• IIB - - "-
• IIIА - embolectomy+fasciotomy - emergency.
• IIIB - - "-
• IIIC - primary amputation.
Fasciotomy it is carried out only at operations on the bottom
finitenesses.

33. THANK YOU