A Cohort Study of Upper Critical Limb Ischemia Secondary to Atherosclerotic Occlusive Disease

Introduction - Introduction: upper critical limb ischaemia (UCLI) secondary to atherosclerotic occlusive disease is rare. Accordingly, revascularisation indications and outcomes remain unclear. In this relatively large series, we review our experience in managing this condition. Methods - Patients and Methods: This is a cohort study of patients presenting to a tertiary referral centre with UCLI (rest pain and/or tissue loss) between January 2012 and December 2016. Patients with acute upper limb ischaemia or arm claudication were excluded. All patients underwent full imaging (CT/MR or CO2 angiography). Results - Results: during the study period, 20 male patients with 25 ischaemic limbs and 7 female patients with 8 ischaemic limbs, met the inclusion criteria. Median (range) age was 59 (17-71) years and 44% were smokers. 93% of patients were diabetic and 80% of those had elevated HBA1c. 89% were hypertensive and 52% had concurrent or previous history of lower CLI. In addition, 74% had end-stage renal disease and 41% had haemoglobin levels <110g/l. 78% of patient were on antiplatelets and statins at the time of presentation. In the affected limbs, the distribution of significant arterial occlusive disease was: 15% subclavian, 0% axillary, 9% brachial, 45% ulnar, 58% radial and 73% palmar/digital. 52% of limbs underwent revascularisation (12 via angioplasty and 5 via vein bypass surgery). 21% (7) limbs were deemed non-reconstructible. 9 patients had significant concomitant circulatory failure secondary to cardiac or septic pathologies. These were managed expectantly. 18% of limbs required digit and/or partial palm amputation. None required major amputation. Overall 1 year mortality was 30%, however, mortality was twice as much in the no-intervention group (40% vs. 20%). Conclusion - Conclusion: In our experience, UCLI secondary to diabetic arteriopathy is fast increasing. Characteristically, the disease is infra-cubital with particular affinity to palmar and digital vessels. Although major amputation is rarely required, these patients tend to have significant comorbidities and poor survival.