Vascular Disorders Specific to the

Upper Limb.
ACUTE UPPER LIMB ISCHEMIA
CHRONIC UPPER LIMB ISCHEMIA
ACUTE UPPER LIMB ISCHEMIA
Embolism
.Heart (arrythmia, myocardial infarct)
.Proximal aneurysm
.Subclavian thrombus related to thoracic
outlet syndrome.
Trauma
.Forced extension/traction injury
.Supracondylar fracture
.Antecubital fossa laceration
Acute on-Chronic Ischemia

Management AULI



Traumatic Intimal Flap/Dissection
.High index of suspicion from history of injury
.Do not relay on appearance of hand
.If pulse absent, assume mayor injury
.Low threshold for angiography.


Embolectomy
Iatrogenic injurie.
.Access for angiography/ endovascular intervention.




CHRONIC UPPER LIMB ISCHEMIA
Aetiology
.Occlusive atherosclerosis.
.Previous radiotherapy
.Arteritis.
History
.Excertional pain/heaviness of arm.
.Symptoms of subclavian steal.
.Manifestations of atherosclerosis.
.Previous radiotherapy.
.Evidence of connective tissue dis.
.Previous fracture/soft tissue trauma.
CHRONIC UPPER LIMB ISCHEMIA
Examination
.Presence of palpable pulse unreliable
.Measure brachial blood pressure
.Repeat after exercise.
Investigation
.Non-invasive blood pressure measurement, exercise

.Segmental pressure
.Finger pressure
.Duplex ultrasound scanning
.Intra arterial DSA
Management
Brachiocephalic Artery
Mild to Moderate Stenosis with
Hemispheric TIAs: Antiplatelet therapy.
Severe Bc Dis causing TIA+/- ULI.
.Endarterectomy/bypass .
.Operative mortality 5%.
.Possible role for angioplasty+ stent
Management
Subclavian/ Axillary artery
Short proximal stenoses/occlusion best
treatment is ballon angioplasty=/ - stent.
Surgical options:
Subclavian transposition
Carotid-to-Subclavian bypass
Axillo-axillary bypass.
Algorithm for Investigation of Pain
on Walking
Calf/Thigh Pain
Claudication
Resting ABPI Reduced Normal
Appropriate
History
Inappropriate
History
Appropriate
History
Inappropriate
History
EXERCISE
TEST
Algorithm for Investigation of Pain
on Walking
EXERCISE
TEST
Fall in
Pressure
Not Fall in
Pressure
VASCULAR
Claudication
NOT
VASCULAR
Algorithm for Treatment of
Claudication
CLAUDICATION
Non Invasive
Assessment
Risk Factor
Modification
Intervention
NOT Indicated
Intervention
INDICATED
Algorithm for Treatment of
Claudication
Structured
Exercise
Program
Symptom
Deterioration
Duplex/IADSA
Stable
Improvement
Angioplasty
/Stenting
Endarterectomy
/Bypass
Confirmed Peripheral
Arterial Occlusive Disease
(ABI<0.95)
Cardiovascular
Risk Assessment
Aggressive Risk
Factor Modification
and
Antiplatelet
Therapy
Diabetes
-HbA1c and/or
-Fasting and postprandial glucose
.Smoking history
-Current and former
.Hyperlipidemia
-Lipid profile
-LP(a?)
Hypertension
-Blood presure measurement
Homocysteine
-Fasting homocysteine level?
Fibrinogen
-Fibrinogen level
Hypercoagulable and arterial
thrombosis
-Coagulation screen
.Diabetes treatment
Normalize HbA1c
.Smoking cessation
-Behavior modification
-Nicotine replacement
Bupropion
Lipid goals
-LDL cholesterol<100 mg/dl
-Reduce triglycerides
-Raises HDL cholesterol
Hypertension treatment
-Control blood pressure
Homocysteine elevation
-Folat/vit B12,B6
Hypercoagulable state
Anticoagulate
.Antiplatelet therapy
-Clopidogrel
or
-Aspirin
Confirmed Peripheral
Arterial Occlusive Disease
(ABI<0.95)
Cardiovascular
Risk Assessment
Aggressive Risk
Factor Modification
and
Antiplatelet
Therapy
Diabetes
-HbA1c and/or
-Fasting and postprandial glucose
.Smoking history
-Current and former
.Hyperlipidemia
-Lipid profile
-LP(a?)
Hypertension
-Blood presure measurement
Homocysteine
-Fasting homocysteine level?
Fibrinogen
-Fibrinogen level
Hypercoagulable and arterial
thrombosis
-Coagulation screen
.Diabetes treatment
Normalize HbA1c
.Smoking cessation
-Behavior modification
-Nicotine replacement
Bupropion
Lipid goals
-LDL cholesterol<100 mg/dl
-Reduce triglycerides
-Raises HDL cholesterol
Hypertension treatment
-Control blood pressure
Homocysteine elevation
-Folat/vit B12,B6
Hypercoagulable state
Anticoagulate
.Antiplatelet therapy
-Clopidogrel
or
-Aspirin
Abdominal Pain and Arterial
Disease .
Differential Diagnosis
Mesenteric ischemia: often too late!
Suspect inpatient with other symptoms or
signs of vascular disease (angina pectoris,
intermittent claudication, stroke) who
complains of abdominal pain, weight loss,
fear of food, post prandial diarrhoea.
Abdominal Aortic Aneurysm.
Differential Diagnosis
Perforated DU
Acute pancreatitis
Renal Colic
Lumbar osteoarthritis
AAA can be Symptomatic
PAIN can be UNUSUAL
Back pain
Loins pain
Flank pain
Genital pain.