Hybrid reconstruction of the upper limb in a patient with chronic limb ischemia

Introduction

Hybrid vascular interventions performed in patients with chronic limb ischemia are considered minimally invasive techniques for treating complex multilevel arterial occlusive disease. ¹ Although their clinical efficacy in chronic lower limb ischemia is well reported in the literature,^2,3 hybrid revascularization procedure in the upper limb due to severe peripheral arterial disease has never been described in the literature. We report the case of a 42-year-old woman who presented to the vascular clinic with a critical upper limb ischemia, stage IV according to the Rutherford classification ⁴ for limb ischemia. An initial intra-arterial digital substraction angiography revealed a high-grade stenosis (>70%) of the peripheral segment of the axillary artery and a hypoplastic brachial artery up to 8 cm above the level of the elbow. The patient underwent a hybrid procedure consisting of balloon angioplasty and secondary stenting of the distal-third of the axillary artery followed by a brachial–brachial bypass using an autologous graft. The patient had an uneventful recovery and was discharged on the fifth post-operative day.

Case report

A 42-year-old woman was referred to our hospital complaining of a cold and painful left upper limb accompanied by numbness and diminished movement, symptoms that appeared gradually over the last month and deteriorated over the last week. The patient had a medical history of hypertension, dyslipidemia, coronary artery disease (previous myocardial infarction treated with percutaneous coronary intervention), severe pulmonary disease requiring home oxygen therapy, chronic current smoker, and an episode of acute left upper limb ischemia, which was surgically treated by brachial embolectomy approximately 8 months ago with an uneventful recovery. At clinical examination, her upper limb was slightly pale and cold, with absent brachial and peripheral pulses as well as with motor and sensory deficits. The patient did not consent for a complete open vascular repair and was therefore scheduled for a programmed hybrid revascularization. Furthermore, her past blood test results for thrombophilic and autoimmune screen were sought from her first hospitalization and proved to be negative for any disease. Under general anesthesia, direct puncture of the brachial artery was made for insertion of a short 7-Fr sheath (Terumo Medical Corp., Tokyo, Japan). Retrograde endoluminal passage of a 0.035-inch J stiff Glidewire (Terumo) was performed, supported by a 5-Fr Vertebral Glidecath catheter (Terumo). Once the guidewire reached the origin of the left subclavian artery, a 6-Fr Super Arrow sheath (Arrow International, Inc., Reading, PA, USA) was advanced into the upper third of the axillary artery.

The on-table angiography performed by the portable C-arm device showed a high-grade (∼80%) stenosis of the distal third of the axillary artery as well as a hypoplastic brachial artery extending immediately after its origin up to 8 cm above the level of the bifurcation at the elbow. These angiographic findings completely matched the preoperative imaging at the angiography suite (Figure 1). OPEN IN VIEWER

Initially, a balloon angioplasty of the distal segment of the axillary artery was performed twice but with suboptimal result (residual stenosis >50%). Subsequently, a 5 mm self-expandable stent was advanced and deployed into the stenotic lesion with the completion angiography showing normal patency of the stent and satisfactory outflow to the brachial artery (Figure 2). OPEN IN VIEWER

The open part of the hybrid revascularization that followed included a proximal (upper third of brachial artery) to distal (just proximal to the brachial bifurcation) brachial–brachial bypass using as an autologous graft the ipsilateral reversed basilic vein (Figure 3). OPEN IN VIEWER

The patient was discharged on the fifth postoperative day without complications and with a normal color duplex scan; 1 and 6 month follow-up showed normal patency of the hybrid procedure with palpable peripheral pulses on clinical examination.

Discussion

In hybrid vascular reconstructions, patients are treated using both endovascular and open revascularization procedures simultaneously. Hybrid vascular procedures comprise approximately 5–21% of all vascular reconstructions.^5,6 Combining the endovascular procedure with the open intervention in the peripheral vascular field is a less aggressive technique with excellent immediate technical success, and primary-, primary-assisted and secondary patency rates as well as limb-salvage rates in patients with chronic limb ischemia have been well reported.^7–9 Patients undergoing hybrid revascularization procedures benefit more due to shorter operative duration, shorter hospital stay (including intensive care unit stay), and diminished blood loss, especially those patients with multiple comorbidities. ¹⁰ On the other hand, the therapeutic role of hybrid vascular procedures in the emergency setting is not yet established ¹⁰ despite the fact that the increase in prevalence of peripheral arterial disease raises the percentage of acute limb ischemia attributed to thrombosis ¹¹ and the risk of limb loss in acute limb ischemia ranges from 5% to 30% with mortality rates approaching 18%.^12–14

Typical atherosclerosis is rare in upper extremity arteries and more typical-appearing atherosclerotic lesions are seen occasionally in axillary, brachial, and forearm arteries. Furthermore, upper extremity arterial ischemia is present in less than 5% of patients presenting for medical treatment of extremity ischemia. ¹⁵

In our opinion, the presence of ischemic rest pain of the patient’s upper limb resulted either due to a chronic state of microembolic episodes from a proximal atherosclerotic plaque to the periphery with a gradual compromise of the arterial vascular bed or a subacute arterial thrombosis due to plaque rupture with subsequent loss of adequate arterial outflow to the peripheral vasculature. We assume that the hypothesis of a proximally located atherosclerotic plaque as a source of embolic phenomena is more applicable to the patient’s past medical history, her major cardiovascular risk factors, and the intraoperative findings. We described a rare case of a hybrid approach to a chronically ischemic upper limb with rest pain. In our opinion hybrid revascularization procedures in the upper limbs could minimize surgical stress and trauma, possibly avoiding complications of major surgery and providing the benefits reported for the lower limbs.

Conclusion

We presented the first case of a hybrid revascularization procedure in a patient with critical upper limb ischemia due to arterial atheromatous occlusive disease. Our experience demonstrated that hybrid revascularization procedure in the upper limb is technically feasible, safe for the patient, and should become a part of the armamentarium of the modern vascular surgeon.