Upper Extremity Flashcards
What is the difference between primary and secondary Raynauds? What’s more common?
Primary is most common. Secondary is due to another condition, less common but more serious.
What conditions are associated with raynaud’s phenomenon?
80-90% is related to scleroderma. Other conditions: SLE, rheumatoid arthritis, mixed connective tissue disease
What are symptoms of Raynauds?
Digital ischemia associated with cold, caffeine or emotional distress
What are 10 conditions related to small vessel upper extremity ischemia?
- Scleroderma - SLE - Rheum arthritis - Sjogrens (dry eyes/mouth) - Buergers - Hand arm vibration syndrome - Fibromuscular dysplasia - Malignancy - Hypersensitivity angiitis - Frostbite
Name 8 conditions related to large vessel upper arm ischemia
- Atherosclerosis - most common - left subclavian - Embolic - a fib, usually lodges in brachial - Aneurysms - Trauma - TOS - Trauma - iatrogenic access - GCA - Takayasu - Access related steal - 10-15% brachial access
What medical treatment options are there for Raynauds?
Conservative - tobacco/cold avoidance Nifidipine Losartan Bosentan (endothelium receptor blocker) for scleroderma
What surgical treatment options are there for upper extremity small vessel disease?
Thoracic sympathy to my for digital vasospasm with ulceration - symptoms return in 3-6 months Periarterial digital sympathectomy has also been described
What are the compartments of the forearm?
Volar, lateral, extensor
What is the most common cause of acute upper arm ischemia?
Emboli from cardiac source
Where is the 1st part of the axillary artery?
Superior to pec minor
Where is the 2nd part of the axillary artery?
Posterior to pec minor
Where is the 3rd part of the axillary artery?
Inferior to pec minor
When exposing the basilic vein or brachial artery in the bicipital groove, which nerve can lead to hyperesthesia or anestheisa of medial doral surface of the forearm?
Median antebrachial cutaneous nerve
Where does the radial artery course in the wrist (between which 2 tendons?)
Flexor carpi radialis and bracioradialis
In the antecubital fossa is the brachial artery medial or lateral to the biceps tendon?
Lateral. (Median nerve courses medially).
Between which 2 muscles does the ulnar artery course between in the forearm?
Flexor carpi ulnaris and flexor digitorum
Name 7 causes of upper extremity amputation
- Trauma (80-90%) or occupational (hypothenar hammer, vibration induced, quadrilateral space, arterial TOS)
- Vascular disease - atheroscloersis, embolic
- Tumours
- Infection
- Iatrogenic (catheterization, vasopressor, vascular access)
- Congenital anomaly
- Vasospastic/small vessel: Raynaud, Buergers, Radiation induced
What digital pressures will healing generally occur at the hand level? What about wrist level?
Hand - 40 mm Hg
Wrist - 60 mm Hg
What orientation of I-I would you use to “open up” the aortic arch?
LAO
What orientation of the I-I would you use to display the bifurcation of the brachiocephalic artery?
RAO 20 degrees
Name 7 “high risk”/unfavourable characteristics of arch vessel disease for endovascular treatment
- Occlusion (vs stenosis)
- Eccentric (vs concentric)
- Vessel origin in ascending aorta
- Heavy calcification
- Ulceration
- Symptomatic
- Ostial lesion
Where is the V4 segment (vertebral artery)?
Intracranial, intradural protion of the vertebral artery from atlanto-occipital membrane up to basilar artery
Where is the V3 segment (vertebral artery)?
From top of C2 to atlanto-occipital membrane at base of skull
Where is the V2 segment (vertebral artery)?
From C6 transverse process to C2
What is the most common pathologies associated with vertebral disease in the V1, V2, V3 and V4 segments?
V1 - Atherosclerotic ostial lesions
V2 - extrinsic compression, traumatic/spontaneous AV fistula (due to fixation of adventitia to the periosteum)
V3 - Trauma and arterial dissection (the artery is most mobile in this section therefore vulnerable to mechanical injury)
V4 - AV fistula, aneurysmal degeneration
Where is the V1 segment (vertebral artery)?
From subclavian to entrance of C6 transverse process.
Name 10 symptoms associated with vertebrobasilar ischemia
- Disequilibrium
- Verigo
- Diplopia
- Cortical blindness
- Alternating paresthesia
- Tinnitus
- Dysphagia
- Dysarthria
- Quadriplegia
- Drop attacks
- Ataxia
- Perioral numbness
What are 2 minimum anatomic requirements to justify vertebral artery reconstruction?
- Greater than 60% stenosis in BOTH vertebral arteries if both are patent
- Complete occlusion or >60% stenosis of dominant vertebral artery if other one is hypoplastic, occluded, or ends in posterior inferior cerebellar artery.
What are complications associated with proximal vertebral artery reconstructions?
- Vagus/recurrent laryngeal nerve palsy 2%
- Horners 8-28%
- Lymphocele 4%
- Chylothorax 0.5%
- Stroke 1% (if combined with carotid operation, 6%)
What is the most common operation used to reconstruct vertebral V1 disease?
Transposition of the proximal vertebral artery onto the adjacent carotid artery
What are 5 causes of arch vessel aneurysms?
Vascular:
Infection/Inflame: syphillis, tuberculous lymphadinitis
Neoplasm:
Degenerative/drugs: most degenerative
Iatrogenic:
Congenital: thoracic outlet syndrome
Autoimmune: FMD, cystic medial necrosis, vasculitis
Trauma: trauma
Endocrine:
What are the symptoms associated with arch vessel aneurysms?
Neuro - pain (chest neck abdo), brachial plexus compression, TIA, stroke
H&N - hoarseness from right recurrent laryngeal nerve compression
CV - rupture
Resp - resp insufficiency from tracheal compression, hemoptysis
Abdo
GI - dysphagia from esophageal compression
GU
Extremities: UE acute and chronic ischemia from thromboembolism
Incidental: Most often
**What are clinical features and complications of aberrant right subclavian artery?
- Asymptomatic
- Kommerell’s diverticulum
- Non-recurrent right RLN
- Thoracic duct that empties into right jugulosubclavian confluence
- Compressive Symptoms:
- Dysphagia Lusoria – esophagus compressed
- Tracheal compression - cough
- Emboli to arm
- Thrombosis
- Rupture
Name 6 physical signs associated with subclavian artery aneurysms
- Supraclavicular bruit
- Absent or diminished UE pulses
- Normal pulses with signs of microembolization (“blue finger”)
- Sensory and motor signs of brachial plexus compression
- Vocal cord paralysis
- Horners from compression of stellate ganglion cervical sympathetic chain
How are aberrant right subclavian artery aneurysm repaired in the elective setting:
Incision/approach? 3 options
Incision/approach:
- Staged. Extraanatomic bypass (carotid subclavian) to reconstruct the aberrant subclavian artery followed by thoracotomy to oversew the origin of the Komerrell diverticulum.
- Side biting clamp exclusion - right or left posterolateral thorocotomy depending on position of the aortic arch, or median sternotomy.
- Hybrid approach: carotid subclavian bypass + TEVAR
