Upper Limb Arterial Doppler - Part 4

Embolism in Upper Limb Ischemia

The other common problem, which can come up in upper limb and cause ischemia is embolism.

Embolism is more common in the upper limb as compared to lower limb, and one of the most common sites of embolism is the heart, the mitral valve.

This is a patient who came with acute pain in the right upper arm and we can see that there is a source of embolism at the level of mitral valve.

Another patient who came with severe arm pain, one fine morning. Again, we can see a fresh embolism in the auxiliary artery and the cause is again a vegetation at the level of the mitral valve.

Sometimes the embolism can affect the distal arteries. There's a patient who came with pain in the hand, and typically what we see is that the digital arteries, namely the ring finger arteries are occluded.

This can sometimes be difficult to evaluate, but if one is very careful with the digital arteries, we can come to this diagnosis.

Approach to Upper Limb Artery Ischemia

As far as upper limb artery ischemia is concerned, it is very important to have an organized and systemic approach.

It is very important to find out if the patient has some underlying arterial disease or the patient has an abnormal vaso spastic response.

And this is very important to plan the therapeutic procedure.

Trauma in Upper Limb

Trauma is very common in the upper limb and we have a variety of causes of trauma.

One of the most common cause of trauma is an industrial trauma.

This is a patient actually who came with an industrial trauma. There's a large hematoma happening in the muscle and the brachial artery is totally occluded.

Another patient who came early in the morning with an industrial trauma, we can see there's a lot of soft tissue laceration there, and we can see a complete obstruction of the brachial artery involving the radial as well as the NAR artery.

Agricultural Trauma

This patient had quite an unusual AR agricultural trauma, so while he was working in the field and cutting the crops, one of the instrument happened to hit his elbow.

He had laceration in the brachial artery and we can see that there is no walls in the brachial artery and there's a huge thrombus there.

Traumatic AV Fistula

This patient had, again, a traumatic AV fistula at the level of the elbow, and we can see that there's a communication between the brachial artery and the vein.

This patient again had traumatic AV fistula in the fingers. Her hand accidentally went into a machine and we can be sure that this is an AV fistula By looking at the radial vein, the radial vein shows a pulsatile flow telling us that there is a communication between the artery and the vein.

Vascular Malformation from Fight Injury

This is yet another patient who was involved in a fight and after that he developed a swelling on the palm and we can see that there's a large vascular malformation on the palm.

If you look at the wave form, the arteries show a high diastolic flow and the veins show a pulsatile flow.

And if you look at these two wave forms, one can be sure that one is dealing with an AV fistula.

This was of course confirmed on a geography and that is the clinical picture of the same patient.

Traumatic Aneurysm

This patient had an injury with a stone and what we see is a localized dilatation of the distilled radial artery because of a traumatic aneurysm.

Electrocution Injuries

As I said earlier, electrocution injuries are more common in the upper limb as compared to the lower limb.

This is a patient who was actually working with one of the electrical companies and during his job accidentally touched a wire.

He came to us with osis and the entire forearm was black in color.

And what we see is that the entire under artery and the radi artery were completely occluded.

This is a bad injury to happen to someone who is working.

Neonatal Upper Limb Ischemia

Upper limb ischemia can also be because of hydrogen injuries.

This is story of an eight day old baby who came to us for upper limb dola.

This child was born premature and had a tough time in the first two days of life.

The child presented to us after eight days with the pulses not being felt.

So what we observe here is that there is a thrombosis of the entire venous system, and if you look at arteries, there's flow in the brachial artery in the proximal radial and al artery.

However, there is no flow distally.

If you look at the waveforms, there is a high resistance waveform in the subclavian artery and the brachial artery, but the brachial artery beyond the bifurcation, the vessels do not show any flow in the radial and ular artery.

So it's very important to look at proximal artery of waveform to diagnose something which is happening distally.

Machine-Related Injury

This is another patient who used to work a lot with some machines and came with his chiia in the hand.

And what we see is a soft tissue thrombus in involving the distal radial artery.

This was adequately treated.

Compartment Syndrome

Of course One can have compartment syndrome in the upper limb.

This patient, again, had history of trauma, then came with soft tissue edema.

And as we know that in a compartment syndrome, there's a lot of soft tissue edema and therefore there is increased resistance to the blood flow.

And one of the diagnostic criteria of a compartment syndrome is a pan reversal of flow in the diastole.

So if you look at the bural artery, the radial and the artery proximal portions, we see that there's a reversal flow happening throughout the diastole.

And this is diagnostic of a compartment syndrome.

Use of Upper Limb Arteries in Bypass Surgery

Upper limb arteries are also used for a bypass surgery, typically in the coronary bypass surgery.

But before anyone lifts up the radial or the NAR artery, one has to be very sure that the Palmer Arche is patent.

And the test for this is known as Alan's test.

So typically what we do is we look at the radial artery, compress the lar, look at the nar, compress the radial, and look out for elevation and veracity.

As we have already described, if there is no increase in velocity as is seen in this case, that means the Bama arch is not patent, the arteries are affected, and lifting up the radial or the ular artery in this patient would not be a right thing to do.

Summary

So overall, as far as his chiia is concerned, it's very important to differentiate between large arteries and smaller arteries.

It is very important to differentiate between obstruct lesions and abnormal vasos spastic response.

As we said, trauma is very common and of course it upper IES are used for access graft, which is a different topic altogether, and it is also important to look at the bombach patency.

Thank you so much.