The presentation is acute upper limb ischaemia classified as Rutherford grade IIa. The limb is not immediately threatened: there is no motor or sensory loss, no muscle tenderness, and arterial Doppler signals remain audible at the wrist. Upper limb function is not a critical quality-of-life concern.
Despite this initially non-threatened picture, regular clinical review shows the limb is not remaining stable on conservative measures alone, triggering escalation.
The patient was initially managed with conservative management with systemic anticoagulation (heparin) alone, supported by intravenous fluids and supplemental oxygen.
The goal of that approach — for the upper limb to remain viable without deterioration over the following days of regular review — was not met. This protocol addresses the next step.
After failure of conservative anticoagulation, management escalates to a surgical intervention carried out under local anaesthesia, with anaesthetic support present.
Full eligibility criteria, operative steps, intraoperative assessment, and subsequent management are detailed in the complete protocol.
The primary goal is restoration of visible perfusion and a palpable wrist pulse.
DOI: 10.1016/j.ejvs.2019.09.006
Some patients with upper limb ischaemia appear to have no immediate threat to their limb, (no motor or sensory loss, no muscle tenderness, audible arterial signals at the wrist on Doppler; Rutherford grade IIa) and conservative treatment with AC alone may be appropriate.
For a patient with acute ischaemia of the upper limb, conservative treatment with anticoagulation alone is not recommended if the arm is threatened, or if limb function is important to quality of life.
Most patients with upper limb ischaemia are treated surgically by brachial embolectomy (Fig. 12); bypass surgery is seldom required acutely.
The default should be surgery under local anaesthesia, with an anaesthetist present, and with the option for intravenous sedation and resuscitation, if required.
Alternatively, the ischaemic hand can be placed in a sterile clear plastic bag during the surgery, and if embolectomy restores visible perfusion and a palpable wrist pulse, check angiography may not be needed.
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