Management of Upper Extremity Arterial and Venous ...
Transcript of Management of Upper Extremity Arterial and Venous ...
Management of Upper Extremity Arterial and
Venous Occlusive DiseasesCLAUDIE SHEAHAN MD
PROFESSOR OF CLINICAL SURGERYLSU SCHOOL OF MEDICINE
Upper extremity arterial disease
• Rare – less than 5% of PVD• Dutch study –
– Prevalence 2.3% diabetics – 0% non-diabetics
Clinical Presentation
• Episodic - Spastic• Claudication• Tissue loss
History and Physical
• Symptoms c/w connective tissue disorders– Arthralgias– Dysphagia– Sclerodactyly– Xeropthalmia– Xerostomia
History and Physical
Also look for signs of• Malignancy• Hypothyroidism• Frostbite• Trauma• Vibrating tools• Drug use
Examination
• Color change• Digital pitting• Digital ulcer • Gangrene
Exam
• Palpation of pulses• Auscultation for bruits• Adsons maneuvers-should be
done sitting• Allens test
Allen’s test
Collateral flow across the palmar arch
Cold provocation testing
Low specificity and reproducibility
Cardiac echo
Look for embolization
potential
X-Rays
• Cervical rib• Soft tissue atrophy• Distal phalangeal tuft
reabsorption
Biopsy
• Skin for vasculitis• SSc atrophy of epidermis and adnexal fat• Arteritis- wall necrosis
Vascular lab• Multiple level segmental
pressures • Multiple level pulse volume
plethysmography (PVR)• Digital pressures /PPG• ABI• DBI (digital brachial index) ≥0.75
Vascular lab
• Demonstrate symmetry – Between arms– Lower extremities
• Gradient 30-50 mmHg with subclavian artery occlusion
• Digital plethysmography for differentiating vasospasm vs occlusive lesion
Angiography
• Aortic arch: atherosclerosis, ulceration, aneurysms
• TOS maneuvers • Retrograde flow in vertebral
“Subclavian Steal”• Vasodilators, hand warming,
magnified view
Angiography in collagen vascular diseases
• Absence of calcium• Total occlusion vs string • Multiple segmental lesions • Less developed collaterals
Upper extremity arterial disease
Occlusive vs. Spastic
Raynaud's Syndrome
•Vasospastic•Primary•Raynaud’s Disease
•Idiopathic
•Obstructive•Secondary•Raynaud’s Phenomena
Primary Raynaud’s
• Exaggerated response to cold, emotional stimuli
• 3 stages: White, Blue, Red• 15-20min episodes• Pain usually absent • Thermal threshold varies 17-26°C
Primary Raynaud’s
• Most common• Benign• Does not lead to severe ischemia
Secondary Raynaud’s
• More likely to progress to severe occlusive lesions within the digital arteries
• Rest pain and ulceration• Associated with Systemic Sclerosis SLE, RA, mixed collagen disease
Epidemiology
• Mostly women• Median age onset 14• Prevalence varies with climate• Study from Portland 30%
incidence• Higher risk in first degree
relative
Pathophysiology
“Local asphyxia of the extremities" was a result of "increased irritability of the central parts of the cord presiding over the vascular innervation"
-Maurice Raynaud 1862
Pathophysiology
“Local fault”
-Sir Thomas Lewis 1930
Bloodwork
• CBC• ESR/CRP• ANA• Biochemical profile• Thyroid function• RF• CXR/thoracic outlet
Nailfold Capilloroscopy
• Early manifestation of scleroderma
• Dilated capillaries, areas of avascularity
Nailfold Capilloroscopy
• Nailfold capillaries lie parallel rather than ꓕ
• Abnormalities not present in vasospastic disease
• Independent predictor for SScdevelopment
1° vs 2° Raynaud's
• Digital ischemia may precede systemic manifestations of these secondary diseases, makes diagnosis more difficult
• % of patients who go on to develop secondary Raynaud’s
Management of Primary Raynaud’s
• Cold avoidance, Gloves• Stop smoking• Stop beta blockers• Stop ergot preparations
(migraine therapy)• Biofeedback doesn’t work
Medical management of Raynaud's
First line therapy – calcium channel blockers
–Procardia XL (nifedipine) 30-60mg qd to bid–Norvasc (amlodipine) 5-10mg qd
Medical management of Raynaud's
Second line therapy with proven efficacy• Angiotensin II RCP blockade (losartan) • ACE Inhibitors (enalopril)• (Prozac) Fluoxetine• Alpha blockers (prazosin)
Alpha blockers reserpine
Medical management of Raynaud's
• Topical vasodilators (GTN)• IV prostanoid (Iloprost)• Endothelin RCP antagonist (Bosentan) • +/- antiplatelets
PDE5 Inhibitors
• Increase availability of NO• Second choice for secondary Raynaud's• Sildenafil (Viagra) 20-25 mg TID
Raynaud's syndrome disordersless than 1% of all Raynaud's
• Immunological and connective tissue disorders– Scleroderma– Mixed CT disease– RA– SLE– Dermatomyositis– Polymyositis– Hep B antigen induced vasculitis– Sjogrens syndrome– Drug induced vasculitis– Hypersensitivity angiitis– Undifferentiated CT disease– Antiphospholipid syndrome
• Obstructive arterial diseases– Atherosclerosis– buergers syndrome– TOS
• Environmental conditions– Vibration injury– Direct arterial trauma– Cold injury
• Drug induced Raynaud's syndrome without vasculitis– Ergot– B blockers– Cytotoxic drugs– OCPS
• Miscellaneous– Vinyl chloride disease– CRF– Cold agglutinins– Cryoglobulinemia– Neoplasia– Neurologic disorders– Endocrine disorders
Small Vessel Occlusion
Mechanism of obstruction is variable–Autoimmune vasculitis - widespread digital and
palmar artery occlusions
Small Vessel Occlusion
Vibrating tools- fibrotic form of
palmar and digital artery obstruction
- presumably shear stress
Small Vessel Occlusion
Pathophysiology–Hypercoagulable states–Embolic–Atherosclerotic–Renal failure
Small vessel occlusion
Gangrene • Usually occlusive disease-either digital or palmar arch. • BUT a proximal embolizing or obstructing lesion should be
looked for• Process of digital gangrene is different from necrosis-it is not
suppurative but a process of desication and mummification
Medical management
• No abx ointment-will dessicate
• Occasional suppurativeprocess requires iv abx, possible debridement
• Auto-amputation
Surgical therapy
• Cervical thoracic sympathectomy results are too short
• Perineural neurectomy• Fat grafting• Botox• Occasionally PTA
Surgical therapy
• Amputation rarely indicated• Spinal cord stimulation
Scleroderma
• Raynaud's phenomena present in 95% pts
• 40-50% pts will have a digital ulcer in their lifetime
Hypothenar Hammer Syndrome
• Male• Sudden onset• Unilateral
Hypothenar Hammer Syndrome
• Visible/palpable mass by hypothenar eminence due to ulnar artery aneurysm
• Aneurysm may embolize• May also present with thrombosis
Hypothenar Hammer Syndrome
Vasculitis of Malignancy
• Hairy cell leukemia– Systemic necrotizing vasculitis
• “Paraneoplastic” vasculitides• Vasculitis with solid tumors
Drug Abuse Vasculitis
• IVDA of meth or cocaine is associated with pan arteritis
• Accidental arterial injection • Treatment
– Heparin, debridement
Antiphospholipid Syndrome
• Acquired autoimmune disorder• Recurrent arterial and venous thrombosis – anywhere• Thrombotic events treated with anticoagulation
Ergotism
• Most cases due to ergot alkaloid treatments
• Can cause severe spasm of digital vessels - gangrene
Thromboangiitis Obliterans (TO)
• Formerly known as Buerger’s• Segmental medium and small vessel occlusion • Arms and legs• 40-50% pts have history of superficial migratory
thrombophlebitis, Raynaud’s or both
Thromboangiitis Obliterans (TO)
• USA• 10% isolated UE involvement• 30-40% UE and LE involvement• 50% LE
Thromboangiitis Obliterans (TO)
Arterial wall inflammatory infiltrate
Etiology unknown – Tobacco is permissive, probably
causative
Diagnosis
Essential Criteria• Onset of sx <45
• Tobacco use
• No disease proximal to popliteal artery
• No disease proximal to distal brachial artery
• Objective documentation distal occlusive disease
Supportive Criteria• Superficial thrombophlebitis
• Raynaud’s
• UE involvement
Differential Diagnosis
Must exclude:• Proximal embolic source• Trauma and local lesion• Autoimmune disease• Hypercoagulable state• Atherosclerosis• Atherosclerotic risk factors (DM, HTN, Hyperlipidemia)
Angiography
• Symmetric
• Radial or ulnar occlusion
• Segmental rather than diffuse
• Extensive digital and palmar artery occlusive disease
Treatment
• Stop smoking• Palliative• Remissions related to resumption of smoking• Limb salvage not as good as with atherosclerosis• Normal life expectancy, no coronary involvement
Large Vessel Arteritis
• Giant Cell• Radiation induced
Giant Cell Arteritis
Systemic GCA (temporal arteritis) vs. Takayasu’s arteritis
Giant Cell Arteritis
Systemic GCA (temporal arteritis)• Usually carotid artery branches
• But any branches
• Most often complaint is severe pain along course of temporal artery
• Women older than 50
Systemic GCA
Diagnosis• Biopsy
• Duplex may be helpful
Treatment• Prompt steroid therapy
• MTX
• Cyclosporin, Azathioprine
• TNF inhibitors
• Pyrimidine synthesis inhibitors
Takayasu’s Arteritis
• Younger patients, female more often
• Smooth tapered stenosis of subclavian, axillary, brachial
• Can cause stenosis of aorta and its branches, main difference is pulmonary artery involvement
• Thoracic aortic aneurysm 17x risk
• AAA 2.4x risk
Takayasu’s Arteritis
Pediatric
• Not as strong sex predilection
• Heart failure is common
• 75% survival at 20 yrs, heart failure driven
• HTN
• Also, myocarditis, coronary artery involvement, valvular involvement, pulmonary involvement
Takayasu’s Arteritis
• Two stages of illness– Acute – Chronic
• Same medications used as temporal arteritis
• Results not as consistent as with TA
Surgical Intervention
• Best done in quiescent (chronic) state
• Symptomatic stenosis
• Aneurysmal lesions
Surgical Intervention
• Successful surgery requires bypass to normal artery
• Continue steroid therapy
• PTA higher restenosis rate than expected, 90%
Surveillance
• Follow ESR, CRP
• PET-CT scan
Upper Extremity Acute Arterial Insufficiency
50% - embolization• mostly cardiac• also aneurysm brachiocephalic/subclavian
25% - primary arterial thrombosis25% - iatrogenic
• ABGs• A lines• AVF creation
Upper Extremity Acute Arterial Insufficiency
• Embolization is associated with 25% mortality–Recurrence and embolization to other vascular beds
• Renal, Mesenteric, Cerebral
Revascularization
• Thrombectomy• Endovascular• Combined
Repetitive Trauma
• Quadrilateral space syndrome-axillary artery injury
• Humeral head syndrome- post humeral circumflex artery injury
• Both lead to embolization• Common in throwing athletes
Large Vessel Occlusive Disease
• Atherosclerosis- most common
• Same risk factors as lower extremity
• Diabetes, renal failure lesions may involve large and small vessels
Large Vessel Occlusive Disease
AneurysmSubclavian and axillary – most common
Iatrogenic venous disease
• Trauma• IV access• PICC lines• Dialysis catheters
COVID 19 – Acute Limb Ischemia
• Thrombotic etiology predominates
• Can occur in pts receiving thromboprophylaxis
COVID 19- Acute Limb Ischemia
• Risk factors – Older age– Obesity– Cardiovascular comorbidities
• More typically affects patients with severe COVID-19
• Occurs five to seven days after respiratory decompensation
COVID 19 – Acute Limb Ischemia
• Thrombosis of large or medium-sized arteries have all been reported.
• Small vessel thrombosis leading to digital gangrene is often associated with the administration of vasopressor agents.
COVID 19 – Acute Limb Ischemia
• About 20 percent of patients who present with COVID-19 related ALI have few or no respiratory symptoms.
• Furthermore, ALI can occur during the recovery phase following infection of any severity.