upper limb salvage with endovascular treatment …...the rate of limb salvage following...

CASE REPORT AND REVIEW

Vascular Disease Management® March 2015 36

Upper Limb Salvage With Endovascular Treatment of Acute Axillary Artery Occlusion Secondary to Proximal Humeral Fracture

Acute upper limb ischemia (AULI) is much

less commonly encountered and clinically

recognized than acute ischemia of the lower

limb.1 According to a previous report, the early com-

mencement of revascularization is crucial for limb

salvage in patients with AULI.2 Sudden axillosubcla-

vian artery occlusion is one cause of AULI. How-

ever, it rarely occurs as a complication of proximal

humeral fracture.3 Although there are some reports

on endovascular treatment (EVT) for the manage-

ment of axillosubclavian artery injuries, such as lacer-

ations, pseudoaneurysms, and arteriovenous fistulas,4

there are only a few reports on its application in acute

axillo-subclavian arterial occlusions.5,6 We present a

case demonstrating the value of immediate EVT in

the management of AULI secondary to acute axillary

artery occlusion caused by a closed humeral fracture.

CASE PRESENTATIONAn 82-year-old Japanese male presented with severe

pain in the left shoulder and arm, with discoloration

of hand and fingers, 2 hours after falling at home. His

medical history included osteoporosis and prostate can-

cer that were well controlled with medical treatment.

On admission, his vital signs were stable. On physical

examination performed approximately 2 hours after

Tsuyoshi Isawa, MD1; Kenji Suzuki, MD1; Hideki Abe, MD2

From 1Sendai Kousei Hospital, Sendai, Japan, and 2Sanyudo Hospital, Yonezawa, Japan.

ABSTRACT: Acute axillary artery occlusion associated with proximal humeral fracture is rare.

Traditionally, axillary artery complications associated with humeral fractures are managed with open

surgery. However, open vascular repair presents a considerable challenge to even the most skilled

surgeons. Endovascular treatment (EVT) offers an alternative to surgical management. We describe

the case of an 82-year-old Japanese male with acute upper limb ischemia (AULI) secondary to acute

axillary artery occlusion caused by a proximal humeral fracture. He was successfully treated with

EVT. Unless there is vessel transection, EVT is feasible and offers a minimally invasive and prompt

therapy for AULI resulting from axillary artery occlusion.

VASCULAR DISEASE MANAGEMENT 2015;12(3):E36-E43 Key words: endovascular management, acute upper limb ischemia, proximal humeral fracture

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Figure 1. Radiograph showing proximal fracture of the left humerus before (A) and after closed reduction (B).

Figure 2. Serial computed tomography images of the left axilla showing the axillary artery (large arrow), occluded near the fracture site without contrast extravasation, and a piece of fractured humerus bone (small arrow). Images are viewed in a cranial (A) to caudal (B) direction.

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the fall there were no brachial, radial, or ulnar pulses

in the left arm. There were no open wounds. The

hand and forearm were pale and cool, but the skin of

the fingers was dark, indicating critical ischemia. In

spite of mild hypoesthesia, there was no weakness in

his hand and fingers. His hemoglobin was 9.6 g/dL

and the estimated glomerular filtration rate was 71.9

mL/min/1.73 m2. The serum creatine kinase level was

123 IU/L. An initial radiography of the left shoulder

revealed a three-part fracture of the left proximal hu-

merus with severe medial displacement, according to

Neer classification. To restore blood flow, he under-

went immediate closed reduction under interscalene

brachial plexus block (Figure 1). However, the distal

pulses were still not palpable and the fingers remained

dusky. An early phase contrasted computed tomogra-

phy (CT) scan showed an abrupt obstruction of the

left axillary artery adjacent to the fracture site, without

evidence of contrast extravasation. This finding sug-

gested occlusion associated with an intimal tear caused

by the displaced shaft of the humerus rather than arterial

transection. Late-phase contrasted CT images revealed

a faint visualization of the brachial artery distal to the

occluded axillary artery (Figures 2 and 3). His up-

per limb was thought to be salvageable because of the

lack of weakness in his left hand and fingers.

TREATMENTAt first, thromboembolectomy with a Fogarty cath-

eter or bypass surgery was considered as the primary

procedure. However, there were no experienced sur-

geons on duty at nearby tertiary hospitals who could

immediately perform such operations. Therefore, we

opted for EVT for upper limb salvage. A transfemoral

Figure 3. Three-dimensional computed tomography images of the left axilla from a slight right anterior oblique angle showing axillary artery obstruction (arrow). Early phase (A). Late phase (B).

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approach under local anesthesia was used, with place-

ment of a 6 Fr sheath into the right common femoral

artery. Following intravenous heparin (5,000 U), se-

lective angiography was performed. The axillary artery

was occluded proximally without the visualization of

distal vessels. A 6 Fr JR4 Launcher guiding catheter

(Medtronic) was placed in the left subclavian artery

with the aid of a 0.035˝ angled soft guidewire. Next, a

5 Fr JR4 Trail diagnostic catheter (Fukuda Denshi) was

introduced using the mother-child technique. With

the support of the 5 Fr diagnostic catheter antegradely

advanced to a point just proximal to the occluded part

of the artery, the guidewire was successfully passed

through the occlusion and reached the brachial ar-

tery. The delivery of a Thrombuster II 6 Fr aspiration

catheter (Kaneka Medix) from a femoral artery was

not possible because of the tortuous axillosubclavian

artery. Therefore, we tried to gain access through the

brachial artery. The brachial artery provides a more

direct, shorter, and less tortuous approach for the treat-

ment of axillary artery lesions.

Although several attempts at brachial artery puncture

were unsuccessful using a 0.035˝ antegrade guidewire

as a landmark to obtain retrograde access, we achieved

radial access under fluoroscopic guidance and intro-

duced a 6 Fr long sheath. A 0.018˝ Thruway guidewire

(Boston Scientific) was passed through the lesion in

retrograde fashion, advanced into the guiding catheter

in the left subclavian artery, and retrieved with a Goose-

neck snare (ev3) to gain sufficient backup force. Next,

aspiration thrombectomy via the transradial approach

was performed using an aspiration catheter, and several

large thrombi were aspirated from the axillary artery

(Figure 4). With distal vessel angiographic visualiza-

tion following aspiration, a 6 mm × 40 mm Sterling

balloon catheter (Boston Scientific) was advanced over

Figure 4. Thrombi aspirated from the axillary artery.

Figure 5. Stent deployment.

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the guidewire. The balloon was inflated at 8 atmo-

spheres for 60 seconds. After the balloon dilatation,

the distal blood flow was only partially restored and

the cyanosis of the upper limb did not resolve.

We observed a flow-limiting, angiographically iden-

tifiable dissection that extended from the axillary ar-

tery to the subclavian artery. Therefore, we deployed

a 6 mm × 40 mm SMART Control self-expandable

stent (Cordis Corporation) distally and a 6 mm × 120

mm counterpart proximally, avoiding the origin of

the vertebral artery. Unfortunately, there was a gap

between the stents; therefore, an additional 6 mm × 18

mm Palmaz Genesis balloon-expandable stent (Cordis

Corporation) was placed between them (Figure 5).

After postdilatation, the patency of the vertebral and

internal thoracic arteries was protected and brisk flow

was achieved in the axillary artery within 6 hours of

the onset of symptoms (Figure 6). Strong brachial

and radial pulses became palpable and the cyanosis of

the upper limb disappeared. He suffered a right-sided

cerebellar stroke, which was associated with the pro-

cedure, but symptoms including dizziness and nausea

were controlled with conservative treatment. Double

antiplatelet therapy was initiated with clopidogrel 75

mg/day and aspirin 100 mg/day. He underwent open

reduction and an internal fixation of the proximal hu-

meral fracture 1 month after EVT. He was discharged

well after undergoing rehabilitation, and to date, he

has had no symptoms of residual ischemia.

DISCUSSIONThe most common causes of AULI include embolism

(47%) and thrombosis (28%), whereas trauma accounts

for only 25% of cases.7 In addition to direct arterial

Figure 6. Angiogram confirming abrupt axillary artery occlusion before endovascular treatment (A) and patency of the stented axillary artery after endovascular treatment (B).

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trauma, remote arterial trauma can cause AULI when

traction on a blood vessel causes an injury to the ves-

sel at a site distant from the evident bony or soft tissue

damage.8 In particular, the violent overstretching of

an artery under hyperabduction can precipitate acute

arterial injuries, which can involve a total or partial

rupture of all arterial layers or intimal damage only,

causing lumen occlusion.3,9 Although axillary artery

injury sometimes occurs with shoulder dislocation and

clavicle fractures, it is rarely concomitant with proxi-

mal humeral fractures.10

Although open surgery has become the mainstay of

primary treatment for acute upper limb ischemia re-

lated to trauma, the procedure is technically demand-

ing, even for experienced operators. Furthermore, it

often takes time to obtain reperfusion because of the

anatomical complexity of the arteries that are adjacent

to the clavicle and brachial plexus. In contrast, throm-

boembolectomy with a Fogarty catheter has gained

widespread acceptance as first-line treatment for the

management of nontraumatic AULI. The rate of limb

salvage following thromboembolectomy has been re-

ported as 98%.11

EVT is seldom indicated, and consequently has been

rarely used as the concurrent treatment of both trau-

matic and nontraumatic AULI. To our knowledge,

there are few case reports on EVT for occluded axil-

losubclavian arteries associated with blunt trauma, in-

cluding clavicular and scapular fracture.5,6 However, no

reports on EVT for an occluded axillary artery related

to proximal humeral fracture have been published.

This may be because the number of cases is small. The

humerus is more distant from the axillary artery than

the clavicle and scapula, and fractures of the humerus

rarely compromise the axillary artery.

The occurrence of AULI represents an emergency

indication for surgical intervention to prevent gan-

grene of the affected extremity. If the arm is to be

successfully salvaged in patients with AULI, revascu-

larization should be achieved within 6 hours of the

onset of symptoms.2 Therefore, an immediate access

to vascular surgeons capable of accomplishing complex

operations is crucial. If the restoration of blood flow is

delayed, there is a risk of acute renal failure secondary to

myoglobinemia. However, the immediate availability

of skilled vascular surgeons may be limited, particu-

larly in rural areas in Japan. In this setting, EVT is a

viable alternative to surgery. In the present case, EVT

was used to prevent critical ischemia and successfully

salvage the upper limb of the patient.

In general, EVT is feasible unless there is hemody-

namic instability, vessel transection, or the absence of

an adequate proximal vascular fixation site.4 One ma-

jor advantage of EVT over open surgical repair is that

general anesthesia is not required, enabling faster revas-

cularization and minimizing blood loss. Furthermore,

EVT can be immediately performed after diagnostic

angiography, in which vascular access remote from the

local injury is obtained. Kim et al described the efficacy

of percutaneous aspiration thromboembolectomy us-

ing a 6 Fr or 7 Fr guiding catheter via a transbrachial

approach with placement of a 7 Fr sheath.12 Successful

recanalization was achieved in all 11 patients enrolled

in that study, although no cases of concomitant trauma

such as fractures were included. In our case, although

we made several attempts under fluoroscopic guidance,

we were unable to obtain brachial access. Although

ultrasound-guided retrograde arterial access in the

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brachial artery would have made the procedure faster,

we were inexperienced in the procedure. Therefore,

we opted for a more familiar procedure, radial access

under fluoroscopic guidance. Brachial access usually

allows the use of a 7 Fr sheath. Instead, we obtained

radial access and selected a 6-Fr sheath because a 7-Fr

one was too large to insert into his radial artery. Despite

use of a 6 Fr aspiration catheter, by repeating aspira-

tion and stent placement, a large amount of thrombus

was aspirated and acceptable reperfusion was achieved

within the critical period for limb salvage.

Although 5- to 10-month patency has been reported

in a few cases,13 the long-term results of deploying

stents in the axillary artery have not yet been well

investigated. In the present case we had no alterna-

tive because upper limb ischemia persisted even after

balloon dilatation and the aspiration of the thrombus.

Long-term follow-up is required to confirm stent

patency in this patient.

We believe that, for choosing the type of stent for

axillary artery, the following factors are important:

acceptable flexibility and sufficient radial strength.

SMART Control stents demonstrate these factors.

Therefore, we used these stents to cover the axillary

artery lesion. In general, the axillary artery and super-

ficial femoral artery are similar because they have high

mobility. We speculate that the clinical effectiveness

of the SMART Control stents for both axillary artery

and superficial femoral artery lesions may be similar.

The evidence of the long-term result of the SMART

Control stent for superficial femoral artery lesions has

been established.14 As for a balloon-expandable stent

(Palmaz Genesis), although it was not suitable for ax-

illary artery lesions because of the lack of flexibility,

we had to use it for covering a short gap between the

two SMART Control stents. From our experiences, a

balloon-expandable stent does not increase the likeli-

hood of stent strut fracture if it is short.

There are potential procedure-related complica-

tions associated with the use of EVT for acute axil-

losubclavian artery occlusion secondary to trauma.

The risk of distal embolization during recanalization

of an occlusion must be considered. The placement of

the stent near the origin of the vertebral artery should

be avoided to prevent vertebrobasilar embolization.

Consideration must also be given to the possibility

that traversing the occlusive lesions with a guidewire

may cause bleeding because the occlusion may be

the result of partial or complete arterial transection.

Therefore, a CT must be performed before the pro-

cedure to determine whether there is a hematoma

around the artery or a hemothorax. Either of these

findings suggests the transection of the artery, in

which case open surgical repair is a preferred treat-

ment option.

CONCLUSIONIn the management of AULI, treatment should be

initiated as early as possible after the onset of isch-

emic symptoms. EVT offers a minimally invasive and

prompt alternative to open surgery or thromboembo-

lectomy with a Fogarty catheter for AULI resulting

from an occluded axillary artery. n

Editor’s note: Disclosure: The authors have completed

and returned the ICMJE Form for Disclosure of Potential

Conflicts of Interest The authors report no disclosures related

to the content herein.

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Manuscript received September 8, 2014; provisional ac-

ceptance given November 3, 2014; final manuscript accepted

December 5, 2014.

Address for correspondence: Tsuyoshi Isawa, MD, Sendai

Kousei Hospital, Cardiology, 4-15 Hirose-machi, Sendai,

Miyagi, Japan. Email: [email protected]

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the time factor in arterial injuries. Ann Surg. 1949;130:428-438.

3. Modi CS, Nnene CO, Godsiff SP, Esler CN. Axil-lary artery injury secondary to displaced proximal humeral fractures: a report of two cases. J Orthop Surg. 2008;16(2):243-246.

4. DuBose JJ, Rajani R, Gilani R, et al. Endovas-cular management of axillo-subclavian arterial in-jury: a review of published experience. Injury. 2012;43(11):1785-1792.

5. IIkay E, Rahman A, Ozdemir H, et al. Endovascular stent management of acute traumatic subclavian artery occlusion by intimal flap. Eur J Vasc Endovasc Surg Ex-tra. 2003;6:32-35.

6. Molloy S, Jacob S, Buckenham T, Taylor RS. Percu-taneous repair of an acute traumatic subclavian artery

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8. Quraishy MS, Cawthorn SJ, Giddings AEB. Criti-cal ischaemia of the upper limb. J R Soc Med. 1992;85(5):269-273.

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