Arm artery occlusion

Symptomatic arterial occlusive disease is seen much more in leg than arm.

• However, functional impairment can be much more severe in arm

The key to this is picking up on aetiology and treating specifically for that cause.

Aetiology

• Vasospasm
• Intrinsic arterial disease
  • Atherosclerosis (most common)
  • Usually limited to more proximal arteries
  • ESRF - azotaemic arteriopathy
• Inflammatory
  • Initial inflammatory phase - fever, arthritis, myalgias, ESR
• Embolism
  • Macroemboli are mostly cardiac in origin
  • Typically lodge brachial artery just proximal to deep brachial artery takeoff
  • Forearm/hand ischaemia
  • Microemboli) lodge more distally) are more likely to have an arterial origin - aneurysm/ulcerative lesion within distal subclavian, a/w thoracic outlet syndrome. Unilateral Raynaud's disease is a common presentation of thoracic outlet syndrome.
• Trauma
  • Esp repetitive trauma e.g. manual labour

Evaluation

• Symptoms - colour changes, coolness, numbness, weakness, effort-induced fatigue (large vessel occlusive disease), ischaemic rest pain, tissue loss etc. Raynaud's phenomenon (pallor -> cyanosis -> hyperaemic rubor)
• Laterality - if bilateral, implies systemic cause. E.g. inflammatory
• Risk factors for atherosclerotic disease
• BP in both arms
• Pulses in neck, arms, lower limbs

Labs

• Hypercoagulable state - factor v leiden, antithrombin III deficiency, protein C/S, antiphospholipid antibodies, prothrombin gene mutation, hyperhomocysteinaemia
• Connective tissue disorders - RF, ANA, complement, ESR
• ECG/TTE
• Plain films of neck

Management

• Vasospasm - abstain from tobacco, avoid cold, try vasodilators
• Atherosclerotic risk factor management
• Revascularisation for chronic vessel disease is limited to limb salvage situations for patients with critical ischaemia (tissue loss or rest pain) or debilitating symptoms of effort fatigue
• Acute arterial occlusions should be addressed when diagnosed
• Trauma
  • Should be fixed at time of diagnosis
  • Sometimes end-to-end anastamosis can be done. More often need saphenous graft interposition.

Endovascular therapy

• Used to treat short occlusive segments in proximal vessels, esp left subclavian
• Can be antegrade (femoral) or retrograde (brachial) approach

Open revascularisation

• Proximal subclavian occlusion
  • Carotid subclavian bypass/subclavian transposition
• Axillary artery
  • Occlusive lesions are unusual
  • Commonly trauma or neglected emboli
• Brachial artery
  • Lesions are rare - commonly emboli or trauma
• Radial and ulnar arteries
  • Bypass rarely necessary
  • Again, trauma and emboli