Upper limb ischaemia : a twelve year experience

Du Toit, Johannes Marthinus

Upper limb ischaemia : a twelve year experience

Master Thesis

2014

Publisher

University of Cape Town

Department

Department of Surgery

Faculty

Faculty of Health Sciences

Abstract

Introduction: Upper limb ischaemia (ULI) is a relatively uncommon, but well recognized vascular entity. The sequalae of impaired function or amputation of an arm can be devastating to the individual with loss of independence and / or livelihood. There remains much to be learned that can only be established through good quality studies. This project was aimed at developing a comprehensive, but broad overview of ULI, specific to the population we serve. Aims: The objective was to review the Vascular Surgery Unit’s experience with ULI, with particular emphasis on defining the pattern and distribution of disease and pathological profile, describing key demographic and clinical features and reporting on conventional clinical outcomes. Areas of interest, with the potential for further research, were identified. Methods: Retrospective descriptive study. All patients that underwent a surgical intervention for ULI between January 2000 and December 2011, were included in the audit. Approval from the Department of Surgery Research Committee and Human Research Ethics Committee was obtained prior to accessing data (Appendix 1 & 2).A research folder was compiled for each patient. On completion of the data collection process, the findings were analyzed and compared to current literature on this topic. Results: Sixty-four patients with ULI were managed surgically during the 12 year study period. A male: female ratio of 0.60 (as opposed to 0.96 from 2011 Census figures), was reported. The thrombo-embolic subgroup of patients (n=30), were notably younger than expected (mean age of 55 years) compared to the UEAOD subgroup (n=12, mean age of 57 years). Approximately 48% were of mixed ethnicity, correlating well with 2011 Census figures. Referrals were predominately received from Secondary Hospitals (84%) situated within the Cape Metropole. 55% Presented with acute ULI, of which 40% were classified as Rutherford grade IIa and 17% diagnosed with established compartment syndrome. The majority of chronic ULI patients, presented with signs of tissue necrosis (48%).Other indications for intervention included upper extremity claudication symptoms (31%), rest pain (14%) as well as neuro-vascular symptoms (7%). A disproportionately high prevalence of cigarette smoking (83%,with an average of 31 pack years)was identified in the UEAOD subgroup. 27% Of patients were not receiving adequate pharmacological therapies aimed at addressing pre-existing risk factors, as proposed by the TASC II document. Thrombo-embolism was the single largest aetiological factor identified (47%),with the majority of occlusions (57%) occurring at the level of the brachial artery. A left-sided predominance with a ratio of 2:1, was noted. Approximately 47% of patients with UEAOD, were younger than 55 years. A clear proximal pattern of disease was observed (66% of lesions within the subclavian artery). Eighty-nine procedures were performed in 64 patients (78 open, 5 exclusively endovascular with a combined open / endovascular approach implemented in 6 patients). The 30-day mortality rate was 7.8%. Systemic complications were observed in 13% with 23% sustaining some form of procedural complication. Twenty amputations were performed in 64 patients, of which 6 were major amputations. The 30-day amputation rate after an attempt at revascularization, was 12.5%. Adherence to follow-up was poor (51% at 6 months), limiting interpretation of follow-up data. Conclusion: Although few firm conclusions could be drawn, this review has expanded our overall perspective of ULI, specific to the population we serve. It is anticipated that the publication of our institutional data will create a clinical awareness and facilitate future research projects in this field. A collaborative research effort between South African vascular units will facilitate comparison of different institutional experiences and enable pooled data analysis, perhaps further defining the pattern of upper limb vascular disease by identifying distinct geographical confounders.

Description

Includes bibliographical references.

Keywords

Surgery

Reference:

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Masters

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