Innominate to contralateral brachial artery bypass via ministernotomy with anatomic tunneling for critical ischemia of the left upper extremity.

OBJECTIVES: Scarring from prior bypass surgery and irradiation may compromise revascularization options in critical ischemia due to underlying occlusive disease. Occlusive disease of the axillo-brachial artery is particularly difficult to revascularize under such hostile conditions. METHOD: We present a case of a 58-year-old woman presenting with a painful, pulseless, and cool left upper extremity. The patient had a known history of left upper extremity occlusive disease which was managed by subclavian-axillary artery stenting with re-occlusion and subsequent extra-anatomic left carotid-to-proximal brachial artery prosthetic bypass, which was complicated by stroke. The patient had a history of left mastectomy, axillary node dissection, and external beam radiation therapy. When considering revascularization options, the combination of post-radiation changes and scarring of the conventional operative zones for revascularization posed a high risk for complications. We describe a novel approach for such revascularization, where the inflow source was the terminal brachiocephalic artery, outflow to the upper left brachial artery, with anatomic intrathoracic-to-axillary tunneling through the thoracic outlet after verifying the lack of dynamic extrinsic compression at that level. RESULT: The procedure resulted in resolution of the symptoms and the patient continued to do well 2 years later. CONCLUSION: This case shows that anatomic tunneling through the thoracic outlet can be a viable option for upper extremity revascularization when hostile conditions preclude other anatomic tunneling routes or extra-anatomic options.

Anatomical Variation of the Radial Artery Associated With Clinically Significant Ischemia.

PURPOSE: The purpose of this retrospective review was to investigate the incidence of radial artery anatomical variations in patients with clinically significant distal upper extremity (UE) ischemia. Available anatomical studies report that high takeoff of the radial artery occurs in up to 15% of the population. We hypothesized that there is a higher incidence of high origin of the radial artery in patients with clinically significant ischemia compared with the reported frequency in the general population. METHODS: We performed a retrospective review of all patients who underwent UE angiography for clinically significant hand and digital ischemia in our institution from 2012 to 2016. Data collected included patient age, sex, comorbidities, and modality of treatment. RESULTS: Twenty-six angiograms were performed for UE ischemia meeting inclusion criteria. Eight patients had Raynaud disease or scleroderma. Ten patients (38%) had high radial artery takeoff with radial artery origin proximal to the antecubital fossa. The need for surgical intervention was similar in patients with normal anatomy and those with high takeoff of the radial artery. CONCLUSIONS: Incidence of high radial artery takeoff was found more frequently in patients with distal UE ischemia requiring angiogram than in reported population data. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Intra-arterial thrombolysis of digital artery occlusions in a patient with polycythemia vera.

There are limited therapeutic options for the resolution of digital artery occlusions. Intra-arterial thrombolysis with anticoagulative and thrombolytic drugs successfully restored the blood flow in the affected digital arteries.

Acute Upper Extremity Arterial Occlusion Diagnosed on POCUS in the Emergency Department.

Upper extremity acute limb ischemia (ALI) is a limb-threatening and potentially lethal pathology that is most commonly caused by vascular embolization. Outcomes of limb ischemia are time-sensitive due to the correlation between a longer time from symptom onset to intervention with a vastly higher risk of amputation. In this report, point of care ultrasound (POCUS) was utilized to rapidly diagnose a patient with a proximal right brachial artery embolic occlusion, prompting expedited surgical consultation and successful embolectomy. POCUS can provide a focused vascular examination of the limbs to expedite diagnosis of time-sensitive ALI and facilitate timely medical intervention and surgical consultation.

Brachial Artery Injury Resulting From a Dog Bite in a Pediatric Patient: A Case Report.

Pediatric trauma surgeons frequently encounter severe injuries from animal bites, with dog bites being especially prevalent in children, often leading to facial injuries. This paper details the case of a six-year-old male who suffered a dog bite resulting in a rare proximal right brachial artery injury. The bite caused deep lacerations and avulsion injuries, prompting admission to the trauma center, where nonpalpable right radial and ulnar pulses and arm weakness were observed. Surgical intervention, including wound exploration and brachial artery repair using a saphenous vein graft, successfully restored vascular perfusion. This case underscores the urgency of addressing pediatric dog bite injuries through timely exploration, thorough irrigation, and antibiotic prophylaxis, while also highlighting the need for further research on preventive education and clinical guidelines for assessing vascular injuries in such cases.

Treatment of Acute Type A Aortic Dissection Involving Upper Extremity Reperfusion Injury.

A 70-year-old man underwent emergent primary central repair for acute type A aortic dissection (AAAD) with right upper extremity ischemia. Ascending aorta and hemi-arch replacement concomitant with additional right upper peripheral bypass was performed for persistent right upper arm ischemia. The early reperfusion injury (RI) of the right upper extremity was defined the next day, and managed by continuous hemodialysis (CHD) and infusion therapy, resulting in the arm being salvaged. This is an extremely rare adverse phenomenon, and we herein described its successful treatment with perioperative intensive management following central repair of AAAD.

Trans-femoral thromboaspiration for upper extremity ischemia.

INTRODUCTION: Endovascular trans-femoral access catheter aspiration of thrombus within the proximal subclavian, brachial, radial and ulnar arteries for symptomatic upper extremity ischemic pain has not been previously reported. We describe a case in which a successful clinical outcome was achieved using long length neuro-endovascular aspiration catheters. PRESENTATION OF CASE: A 45 year old female presented with diffuse left upper limb pain. Sonography revealed compromised upper extremity blood flow. Thrombus was identified in the proximal left subclavian artery by CT angiography. Surgical retrograde brachial artery access thrombectomy was performed. Occlusion of the left vertebral artery with embolic infarcts of the cerebellar hemispheres was noted post-procedurally. Trans-femoral mechanical aspiration thrombectomy and angioplasty of the subclavian, brachial, ulnar and radial arteries was subsequently performed with successful recanalization. CONCLUSION: Recanalization of vasculature to the upper arm through safer femoral access can be achieved with thrombo-aspiration catheters of sufficient length.

Arterial Embolisms and Thrombosis in Upper Extremity Ischemia.

OBJECTIVE: Upper extremity ischemia (UEI) is an uncommon condition that can lead to permanent disability. There is a limited understanding of the etiology, management, and outcomes of the disease. METHODS: We retrospectively reviewed the charts of all patients who were diagnosed with "embolism and/or thrombosis of arteries of upper extremity" at our institution from January 2005 to December 2013. RESULTS: Patients diagnosed with embolisms were older (P < .001), more likely to undergo thromboembolectomy (P < .001), had higher rates of hypertension (P = .001), and had longer lengths of hospital stay (P = .002). There were no significant differences in complications or mortality at 30 days and up to 1 year. CONCLUSION: At our center, embolism was found to be the most common etiology for UEI followed by thrombosis and stenosis. Patients presented with embolism were older, were more likely to undergo thromboembolectomy, and had higher rates of hypertension and longer hospital stays.

Using temporal artery biopsy to diagnose giant cell arteritis in a patient with bilateral arm ischemia.

INTRODUCTION: Bilateral upper extremity ischemia is an unusual presentation of vascular disease. Aetiologies include atherosclerosis as well as rheumatologic diseases. History and physical examination are often, but not always, enough to distinguish between aetiologies and guide treatment. PRESENTATION OF CASE: We present the case of a female patient with findings neither typical for atherosclerotic or for rheumatologic disease who was ultimately found to have giant cell arteritis affecting her bilateral upper extremities. She underwent bilateral upper extremity bypasses using saphenous vein grafts. DISCUSSION: This patient presented without symptoms and laboratory findings often seen with GCA, however, biopsy revealed a definitive diagnosis. Treatment options for ischemia secondary to giant cell arteritis are not well-documented in the literature. CONCLUSION: Giant cell arteritis can present in atypical forms, and should remain on the differential when atypical-appearing lesions are found, even in the absence of features usually associated with GCA.

Raynaud syndrome.

Raynaud syndrome (RS) was first described by the French physician Maurice Raynaud in 1862 with the characteristic tricolor change featuring pallor (ischemic phase), cyanosis (deoxygenation phase), and erythema (reperfusion phase) induced by cold or stress. Although the underlying pathophysiological mechanism is unclear, alterations in activity of the peripheral adrenoceptor have been implicated, specifically an enhanced smooth muscle contraction due to overexpression or hyperactivity of postsynaptic alpha 2 receptors. There are 2 ways that RS can appear clinically; isolated, formerly referred as Raynaud disease or now primary RS and in association with other conditions, usually connective tissue disorders (eg, Sjögren syndrome, systemic lupus erythematosus, scleroderma, and rheumatoid arthritis), frequently called Raynaud phenomenon or secondary RS. The estimated prevalence in the general population is 3%-5%, with a higher prevalence in women than in men. The diagnosis is mainly clinical, based on patient descriptions of skin changes. Upper extremity pulse-volume recording is used to rule out proximal arterial obstruction. The differentiation between a vasospastic vs and obstructive mechanism is made using digital pressures and photoplethysmography, where an obstructive mechanism has decreased pressures and blunted waveforms. Cold challenge testing, such as ice water immersion with temperature recovery, is highly sensitive but lack specificity. Serologic screening (antinuclear antibody and rheumatoid factor) is advocated to rule out associated connective tissue disorders. Most patients with RS can be managed conservatively, with avoidance of cold exposure or hand warming. For those in whom conservative management is inadequate, a number of pharmacologic and surgical therapies have been used. Owing to lack of complete understanding of the underlying pathophysiology, targeted therapy has not been possible; rather, therapy has been focused on the use of general vasodilation strategies. In this review, the diagnosis, natural history, and current medical and invasive therapy are summarized.