8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 1/15

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 2/15

 ACUTE UPPER LIMB ISCHEMIA

Embolism.Heart (arrythmia, myocardial infarct).Proximal aneurysm

.Subclavian thrombus related to thoracicoutlet syndrome. Trauma

.Forced extension/traction injury

.Supracondylar fracture

.Antecubital fossa laceration Acute –on-Chronic Ischemia

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 3/15

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.

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 4/15

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.

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 5/15

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

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 6/15

ManagementBrachiocephalic Artery

Mild to Moderate Stenosis withHemispheric TIAs: Antiplatelet therapy.

Severe Bc Dis causing TIA+/- ULI.

.Endarterectomy/bypass .

.Operative mortality 5%.

.Possible role for angioplasty+ stent

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 7/15

ManagementSubclavian/ Axillary artery

Short proximal stenoses/occlusion besttreatment is ballon angioplasty=/ - stent.

Surgical options:Subclavian transposition

Carotid-to-Subclavian bypass

 Axillo-axillary bypass.

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 8/15

 Algorithm for Investigation of Painon Walking

Calf/Thigh PainClaudication

Resting ABPIReduced Normal

 AppropriateHistory

InappropriateHistory

 AppropriateHistory

InappropriateHistory

EXERCISETEST

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 9/15

 Algorithm for Investigation of Painon Walking

EXERCISETEST

Fall inPressure

Not Fall inPressure

 VASCULARClaudication

NOT VASCULAR

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 10/15

 Algorithm for Treatment ofClaudication

CLAUDICATION

Non –Invasive Assessment

Risk FactorModification

InterventionNOT Indicated

InterventionINDICATED

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 11/15

 Algorithm for Treatment ofClaudication

StructuredExerciseProgram

SymptomDeterioration

Duplex/IADSA

StableImprovement  Angioplasty

 /Stenting

Endarterectomy

 /Bypass

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 12/15

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 replacementBupropion

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

-Clopidogrelor 

-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 replacementBupropion

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

-Clopidogrelor 

-Aspirin

Abd i l P i d A t i l

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 13/15

 Abdominal Pain and ArterialDisease .

Differential Diagnosis Mesenteric ischemia: often too late!

Suspect inpatient with other symptoms or

signs of vascular disease (angina pectoris,intermittent claudication, stroke) whocomplains of abdominal pain, weight loss,

fear of food, post prandial diarrhoea. Abdominal Aortic Aneurysm.

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 14/15

Differential Diagnosis

Perforated DU

 Acute pancreatitis

Renal Colic Lumbar osteoarthritis

8/12/2019 Vascular Disorders Specific to the Upper Limb

http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 15/15

 AAA can be “Symptomatic”  

PAIN can be “UNUSUAL”  

Back pain

Loins pain Flank pain

Genital pain.