A Conservative Approach to Acute Upper Limb Ischemia

Abstract

Objectives. Few studies report the use of conservative management in the treatment of acute upper limb ischemia (AULI). A retrospective series is presented from a hospital where a conservative approach is used primarily. Methods. A retrospective analysis of patients treated for AULI in our hospital over a 10-year period was carried out. Results. In our series of 17 patients with AULI, 1 was treated surgically and 16 were treated conservatively with anticoagulation as the primary therapy. Fourteen of 16 patients deemed suitable for conservative therapy were treated successfully (88%). Two patients required surgery after a period of failed conservative management, leading to full resolution of symptoms. This was comparable to published reports using embolectomy as the primary management. Conclusions. In selected patients conservative anticoagulation management (with a low threshold for intervention) is a viable alternative to surgical intervention as a first-line therapy in AULI.

VASCULAR DISEASE MANAGEMENT 2010;7(11):E219–E222

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Introduction

Acute upper limb ischemia (AULI) is an uncommon vascular emergency with severe morbid consequences if unsuccessfully treated. Its clinical features are similar to that of the lower limb and traditionally, the patient has about 6 hours from onset of symptoms to receive limb saving treatment. However, this is dependent up on the site of the arterial occlusion and the development of these ischemic changes depends on the efficiency of the collateral blood supply in the region of the shoulder and elbow.^1–3 Prior to the invention of the Fogarty catheter,⁴ the treatment of acute limb ischemia was mainly conservative; however, few reports exist. Surgical treatment, commonly involving embolectomy, has become the mainstay of treatment for embolic or thrombotic AULI.^5–7 A conspicuous absence of reports utilizing conservative anticoagulation management in AULI exists in the literature, despite the regular use of conservative management in everyday practice as an alternative to surgery. The published literature reports the use of conservative management only in selected patient populations who are in the majority excluded from surgery for medical reasons.^8–15 These patients often did not receive any form of anticoagulation therapy,^13,16 unlike the surgically managed patients. These factors make results about the efficacy of conservative treatment difficult to interpret. Hence, the general consensus reported from the literature claiming that surgery is better than conservative therapy for AULI comes from poorly controlled data. This article presents a retrospective series of 17 consecutive cases with AULI treated by our vascular team over a 10-year period. We present an argument for the use of conservative management with short-term heparin anticoagulation followed long-term warfarin anticoagulation as an alternative to surgery in selected patients.

Methods

We performed a retrospective analysis of patients treated at our large acute multidisciplinary hospital that were admitted with AULI over a 10-year period. Patients were identified from hospital records of echocardiograms, duplex ultrasound scans and arm angiograms. Theater books were cross-checked to make sure no patients were missed and a search was also made through the coding system. Patients with inflammatory vasculitides and Raynaud’s syndrome were excluded, as was minor ischemia not requiring hospital admission and treatment, and critical ischemia. Patient demographics, vascular risk factors, clinical presentation, duplex ultrasound and radiological findings, management and treatment outcomes during hospital admission and long-term follow up were recorded.

Results

In total, 17 patients were identified from the hospital notes search (Figure 1 and Table 1). Their risk factors and site of arterial occlusion were recorded (Table 2 and Figure 2). Sixteen of the subjects had the site of occlusion confirmed either by duplex or by angiography or both. Sixteen cases of AULI were initially treated conservatively and 1 traumatic vascular injury required immediate surgery. Of those treated conservatively, 15 received intravenous heparin and 1 received warfarin anticoagulation since the clinical features in this case spontaneously resolved. Two of the patients who received heparin required surgery because there was no clinical improvement on conservative management. One patient received surgery as his primary management, as the AULI was secondary to trauma and therefore unsuitable for conservative therapy. In total, 3 patients underwent surgery, all having complete resolution of symptoms. One patient who underwent a left subclavian-to-left common carotid bypass represented at 1 month with an ischemic left hand. This was successfully treated with conservative anticoagulation therapy alone. Of the patients who received conservative treatment alone, 2 had arm symptoms at follow-up (Table 3, patients 3 and 16), though it is likely that 1 of the patient’s symptoms were due to a subsequent fractured wrist and unrelated to AULI. These results showed successful long-term anticoagulation treatment in 14 of the 16 patients; an 88% success rate at long-term follow-up (mean 1 year, range 6 months to 5 years) and no patient mortalities (Table 3).

Discussion

The data from this retrospective series of patients show an 88% success rate at long-term follow-up for 16 patients who were initially managed conservatively, with 12% of patients requiring surgery and no mortalities. This overall success rate is comparable to reports using embolectomy as the primary management.^{8–10,12,14,15,17–24} Williams and Bell³ correctly suggest that surgery should be considered in all cases, however, our results suggest that a short-term trial of heparin anticoagulation may avoid surgical intervention with its inherent systemic risks. An initial conservative approach may significantly reduce the operative rate and hence reduce potential operative complications in a generally elderly and comorbid population. Patients presenting with AULI have a tendency to have a large number of systemic medical problems^25,26 which makes them more susceptible to surgical complications. Those with embolism often have ischemic heart disease with atrial fibrillation, cardiac failure or a recent myocardial infarction. Conservative management takes advantage of the anatomical difference when compared to lower extremities of greater collateral arterial supply in the arm. Evidence from the literature and our patient series suggest the ideal immediate management of AULI should be as shown in Figure 3. Furthermore, lifelong warfarin should be considered for all patients. This study involved a limited number of patients. It is noted that the incidence of digital ischemia is higher than expected in this series, and the incidence of brachial ischemia is lower than expected. It is possible that this may have influenced the results, and a larger study would be beneficial.

Conclusion

In summary, this retrospective analysis shows that a large proportion of patients with AULI may be considered for initial conservative treatment in view of a long-term success rate of 88%. In selected patients, conservative therapy may be used as short-term primary management in AULI; surgical intervention can be reserved for failure of conservative therapy and acute traumatic injuries. Successful conservative therapy for AULI has significant benefits in terms of morbidity and mortality in a high-risk patient population.

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E. Jane H. Turner, PhD, MRCS^£, Alexander Loh, FRCS*, Adam Howard, FRCS^§ From the £Department of Surgery, Epsom Hospital, Surrey, United Kingdom; *Barnet Hospital, Enfield, United Kingdom; and §Colchester Hospital, Colchester, United Kingdom. The authors report no conflicts of interest regarding the content herein. Manuscript submitted July 8, 2010, provisional acceptance given July 16, 2010, final version accepted July 30, 2010. Address for correspondence: E. Jane H. Turner, MD, Department of Surgery, Epsom Hospital, Dorking Road, London KT18 7EG, United Kingdom. E-mail: ejhturner@yahoo.com