Thoracic Outlet Syndrome—An Uncommon Cause of Acute Upper-Limb Ischemia

Abstract The superior thoracic aperture is a place particularly vulnerable to the occurrence of tissue conflict and the development of a number of neurovascular changes carrying a risk of upper limb dysfunction. The triggering factor in this case is the pressure on the nerve vascular elements brought about by too large muscles of the chest and neck, clavicle fracture and dislocation of the upper ribs, anomalies in the form of ribs, in the neck, or by apex of the lung tumors. Each anatomical anomaly may be a cause of a number of lesions and lead to the development of the disease. Due to the nature of the oppressed structures, there are two basic groups: neurogenic and vascular. The most common variant giving clinical symptoms is neurogenic thoracic outlet syndrome. In this, the compression ratio, the brachial plexus, and for this reason, the vascular surface of the upper limb dysfunction is often overlooked. However, the vascular variant, and especially arterial sub-variant, is very dangerous because it can give complications even in the form of aneurysms, and even upper limb ischemia. The aim of the study is to present the most common changes in the thoracic outlet causing functional disorders of the upper limb.

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Cardiac troponin I in patients with acute upper and lower limb ischemia

VASA ◽

10.1024/0301-1526.37.4.327 ◽

2008 ◽

Vol 37 (4) ◽

pp. 327-332 ◽

Cited By ~ 1

Author(s):

Koutouzis ◽

Sfyroeras ◽

Moulakakis ◽

Kontaras ◽

Nikolaou ◽

...

Keyword(s):

Upper Limb ◽

Lower Limb ◽

Cardiac Troponin ◽

Cardiac Involvement ◽

Troponin I ◽

Limb Ischemia ◽

Elevated Troponin ◽

Troponin Elevation ◽

Lower Limb Ischemia ◽

Ischemia Group

Background: The aim of this study was to investigate the presence, etiology and clinical significance of elevated troponin I in patients with acute upper or lower limb ischemia. The high sensitivity and specificity of cardiac troponin for the diagnosis of myocardial cell damage suggested a significant role for troponin in the patients investigated for this condition. The initial enthusiasm for the diagnostic potential of troponin was limited by the discovery that elevated cardiac troponin levels are also observed in conditions other than acute myocardial infarction, even conditions without obvious cardiac involvement. Patients and Methods: 71 consecutive patients participated in this study. 31 (44%) of them were men and mean age was 75.4 ± 10.3 years (range 44–92 years). 60 (85%) patients had acute lower limb ischemia and the remaining (11; 15%) had acute upper limb ischemia. Serial creatine kinase (CK), isoenzyme MB (CK-MB) and troponin I measurements were performed in all patients. Results: 33 (46%) patients had elevated peak troponin I (> 0.2 ng/ml) levels, all from the lower limb ischemia group (33/60 vs. 0/11 from the acute upper limb ischemia group; p = 0.04). Patients with lower limb ischemia had higher peak troponin I values than patients with upper limb ischemia (0.97 ± 2.3 [range 0.01–12.1] ng/ml vs. 0.04 ± 0.04 [0.01–0.14] ng/ml respectively; p = 0.003), higher peak CK values (2504 ± 7409 [range 42–45 940] U/ml vs. 340 ± 775 [range 34–2403] U/ml, p = 0.002, respectively, in the two groups) and peak CK-MB values (59.4 ± 84.5 [range 12–480] U/ml vs. 21.2 ± 9.1 [range 12–39] U/ml, respectively, in the two groups; p = 0.04). Peak cardiac troponin I levels were correlated with peak CK and CK-MB values. Conclusions: Patients with lower limb ischemia often have elevated troponin I without a primary cardiac source; this was not observed in patients presenting with acute upper limb ischemia. It is very important for these critically ill patients to focus on the main problem of acute limb ischemia and to attempt to treat the patient rather than the troponin elevation per se. Cardiac troponin elevation should not prevent physicians from providing immediate treatment for limb ischaemia to these patients, espescially when signs, symptoms and electrocardiographic findings preclude acute cardiac involvement.

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Acute Upper Limb Ischemia in a Patient with COVID-19 Pneumonia

Clinical Medical Reviews and Case Reports ◽

10.23937/2378-3656/1410317 ◽

2020 ◽

Vol 7 (8) ◽

Author(s):

Alosaimi Roaa ◽

Albajri Ahood A ◽

Albalwi Roaa M

Keyword(s):

Upper Limb ◽

Limb Ischemia

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Ayurvedic management of Ischemic Gangrene due to Diabetes Mellitus - A Case Report

Journal of Ayurveda and Integrated Medical Sciences (JAIMS) ◽

10.21760/jaims.v2i3.8246 ◽

2017 ◽

Vol 2 (3) ◽

Author(s):

Vikram S. ◽

Saraswathi Devi H.N.

Keyword(s):

Diabetes Mellitus ◽

Upper Limb ◽

Medical Science ◽

Limb Ischemia ◽

Interesting Case ◽

Therapeutic Interventions ◽

Acute Ischemia ◽

Arterial Circulation ◽

Ct Angiogram ◽

Choice Of Treatment

Medical science says that ischemia is a common complication in Diabetes, especially in the lower limb but this is a case presenting ischemic changes in upper limb which is unique and also in such type of acute ischemia amputation is the only choice of treatment to save the life of patient from septicaemia. Such a rare and interesting case was taken at Sri Sri Ayurveda Hospital and handled by proper Ayurvedic line of treatment by which circulation is re-established which saved both limb and life of patient. A patient by name Sundaramma, 62yr Female, visited Sri Sri Ayurveda Hospital on 29/2/2016 with a diagnosis of Right upper limb Ischemia with Diabetes Mellitus and Active TB. The main symptoms were severe pain and burning sensation in Right hand and forearm, discolouration of fingers with ulcers, Bluish black discolouration over right thumb, necrosis, pus dischargeand stiffness, associated with difficulty in movement of right arm, shoulder joint, elbow joint, palm and fingers. Diagnosed as Right Upper Limb Ischemia with Diabetes Mellitus and active TB. Therapeutic interventions like Right upper limb Doppler and CT angiogram were done. Such a complicated case was taken at Sri Sri Ayurveda Hospital, and carefully handled by Ayurvedic methods of management, which was ended up by preventing amputation of the limb and also achieving the re-establishment of arterial circulation.

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Upper Limb Ischemia: 20 Years Experience from a Single Center

Vascular ◽

10.1258/rsmvasc.13.2.84 ◽

2005 ◽

Vol 13 (2) ◽

pp. 84-91 ◽

Cited By ~ 32

Author(s):

Jean Deguara ◽

Tahir Ali ◽

Bijan Modarai ◽

Kevin G. Burnand

Keyword(s):

Upper Limb ◽

Primary Repair ◽

Limb Ischemia ◽

Subclavian Steal Syndrome ◽

Arm Amputation ◽

Locoregional Anesthesia ◽

Vein Bypass ◽

Almost All ◽

Revascularization Procedures ◽

Steal Syndrome

The objective of this study was to review a single center's experience of upper limb revascularization over 20 years. All patients undergoing operative or endovascular upper limb revascularization between June 1983 and July 2003 were identified. One hundred eighty-four upper limb revascularization procedures were carried out on 172 patients. Sixty-one patients had a thromboembolic event (35%), 53 patients presented with a traumatic vascular injury (31%), and 29 patients had symptoms of chronic atherosclerotic upper limb ischemia (17%). Fifteen patients had subclavian steal syndrome, eight patients had thoracic outlet compression, and six patients had iatrogenic injuries of the upper limb arteries. Fifty-five thromboembolectomies were performed, 37 under locoregional anesthesia. Ten patients (18.2%) died from cardiopulmonary causes following embolectomy. Fifteen reversed saphenous vein bypass grafts were performed for traumatic damage. Twenty-seven patients had a primary repair, and five required a vein patch. One patient subsequently had an arm amputation, and two patients died. Twelve patients presenting with chronic arm ischemia had a subclavian angioplasty, 12 patients had a proximal bypass, and in 5 patients, stenoses were stented. The mortality in this group was 6.9% (2 of 29). The mortality for upper limb revascularization was 8.7%. Almost all deaths occurred after upper limb embolectomy, and the mortality of this procedure was similar to that of lower limb embolectomy. Deaths were the result of cardiac comorbidity, and this should be actively sought and treated if outcomes are to improve.

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Bilateral Axillary Artery Aneurysms Presenting as Upper Limb Ischemia

Annals of Vascular Surgery ◽

10.1016/j.avsg.2015.05.031 ◽

2015 ◽

Vol 29 (8) ◽

pp. 1659.e9-1659.e12 ◽

Cited By ~ 2

Author(s):

Kimihiro Igari ◽

Toshifumi Kudo ◽

Takahiro Toyofuku ◽

Yoshinori Inoue

Keyword(s):

Upper Limb ◽

Axillary Artery ◽

Limb Ischemia

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Cervical Rib Surgery: A Study of 20 Cases

TAJ Journal of Teachers Association ◽

10.3329/taj.v17i1.3482 ◽

1970 ◽

Vol 17 (1) ◽

pp. 10-12 ◽

Cited By ~ 1

Author(s):

M Lutfor Rahman ◽

G Mohammod ◽

I Alam ◽

MS Ali

Keyword(s):

Upper Limb ◽

Thoracic Outlet Syndrome ◽

Small Study ◽

Fibrous Band ◽

Private Hospitals ◽

Cervical Rib ◽

Orthopedic Surgeon ◽

Diagnosis And Management ◽

Initial Surgery ◽

Cervical Ribs

Cervical ribs give rise to vascular and neurogenic manifestation in the upper limb due to stretching and friction of neurovascular bundle in the base of the neck by numerous mechanisms that includes cervical ribs, anomalous ligament & hypertrophy of the scalenus anticus muscle. Controversy surrounds the diagnosis and management of thoracic outlet syndrome with or without cervical ribs. This is a small study of 20 cases carried out from 1994 to 2003 at RMCH, and some private hospitals. Out of them, 15 patients (75%) were male and 5 patients (25%) were female. The age of the patients was between 15 to 48 years (mean age 33 years) Unilateral cervical ribs were present in 75% cases and the rest 25% had bilateral cervical ribs. Only 3 patients presented with gangrenous upper limb. One of the patient attended to orthopedic surgeon first and amputation was planned. All the patient were treated through supra clavicular approach by excision of cervical ribs together with fibrous band. Only one patient did not respond to this initial surgery as symptoms persist and re-operation done by excision of first-rib and ultimately that patient become symptom free. In this study, authors explained their own experience of various way of presentation of cervical ribs, aetiology, different modalities of the treatment and their out come. doi: 10.3329/taj.v17i1.3482 TAJ 2004; 17(1) : 10-12

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Clinical experience of upper limb ischemia: a retrospective study

International Surgery Journal ◽

10.18203/2349-2902.isj20201869 ◽

2020 ◽

Vol 7 (5) ◽

pp. 1562

Author(s):

Jitesh Tolia ◽

Arvind Bhatt

Keyword(s):

Upper Extremity ◽

Upper Limb ◽

Primary Repair ◽

Balloon Catheter ◽

Duplex Ultrasound ◽

Limb Ischemia ◽

Diagnostic Methods ◽

Conventional Angiography ◽

Duration Of Symptoms ◽

Catheter Directed Thrombolysis

Background: Arterial disorders of the upper extremity are much less common than those of the lower extremity, but when they result in symptoms of acute or chronic ischemia, surgical or endovascular techniques for upper extremity revascularization may be needed. This study presents a review of the epidemiology, aetiology, and clinical characteristics of upper limb ischemia.Methods: The records of 70 patients with upper limb ischemia who underwent treatment from were retrospectively reviewed.Results: A total of 44 patients were diagnosed by CT. Other diagnostic methods and tools used were conventional angiography and duplex ultrasound. Four cases were diagnosed solely on the basis of a medical history and physical examination. A total of 56 surgeries were performed. Rest of the 14 patients went under conservative therapy. The operations included embolectomy and thrombectomy using a Fogarty balloon catheter (n=32), bypass surgery using the great saphenous vein (n=10), percutaneous catheter-directed thrombolysis (n=8), and primary repair (n=4). Patients with Raynaud’s phenomenon or Burger’s disease were either treated with medication only (n=14) or with sympathectomy (n=2).Conclusions: The duration of symptoms in cases of upper limb ischemia may vary from two hours to a year, depending on the aetiology and severity of the illness. Many debates have addressed whether the time gap between the onset of symptoms and treatment predicts long-term arm function.

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