Surgical and endovascular techniques for aortic arch branch and upper extremity revascularization

INTRODUCTION — Arterial disorders of the aortic arch branch and upper extremity are much less common than those of the lower extremity, but when they result in symptoms of acute or chronic ischemia, surgical or endovascular techniques may be needed. Acute arterial disease, particularly acute embolism and trauma, is more common than chronic disorders (eg, atherosclerosis of the aortic arch branch and upper extremity arteries). The most common etiologies of chronic upper extremity ischemia are atherosclerotic disease and late stenosis or aneurysm related to a prior, perhaps initially missed, traumatic injury. Other less common etiologies, such as arterial thoracic outlet syndrome (with or without poststenotic aneurysm) and upper extremity aneurysm, may indicate the need for upper extremity revascularization.

The surgical and endovascular techniques used to treat the more common aortic arch branch and upper extremity arterial disorders are reviewed. Diseases associated with the need for upper extremity revascularization are reviewed briefly below and presented in more detail in separate topic reviews. (See 'Indications' below.)

INDICATIONS — The main indications for aortic arch branch and upper extremity revascularization are acute limb ischemia, typically due to traumatic upper extremity injury or embolism, and chronic extremity ischemia from arterial stenosis, most commonly related to atherosclerotic disease, and leading to upper extremity ischemic pain or tissue loss [1-3]. The clinical features and diagnosis of acute and chronic upper extremity ischemia are reviewed separately. (See "Overview of upper extremity ischemia".)

Upper extremity arterial diseases that may indicate surgical or endovascular revascularization include:

●Upper extremity embolism – Embolism from the heart (thrombus, valvular vegetations, cardiac tumor) more commonly affects the lower extremities, but embolism to the upper extremity can and does occur with notable frequency. Emboli to the more distal upper extremity may also originate from upper extremity aneurysms or high-grade arterial stenoses. Emboli typically lodge at branch points, most commonly at the brachial trifurcation and occasionally at the takeoff of the profunda brachii, both of which are amenable to embolectomy (figure 1). (See "Embolism to the upper extremities".)

Microemboli in the hand, which manifest as splinter hemorrhages or fingertip cyanosis, are typically due to emboli from axillary or subclavian atherosclerotic lesions [4,5], rather than from a cardiogenic source. (See "Overview of upper extremity ischemia", section on 'Isolated hand symptoms'.)

●Traumatic injury – Trauma is among the more common causes of upper extremity ischemia. The repair of major upper extremity arterial injuries is prioritized according to the presence or absence of other severe, life-threatening injuries that may also need surgical management and the degree of vascular injury. The majority of minor intimal injuries and small pseudoaneurysms from penetrating wounds that are clinically "occult" have a benign natural history and often do not require repair. This is in stark contrast to those clinically apparent injuries (eg, penetrating injury) that result in hard signs of vascular injury, such as active bleeding, enlarging hematoma, and limb ischemia, which require immediate intervention [6]. Intravascular shunts (picture 1) can and should be used to maintain perfusion while higher-priority injuries are being addressed in the multitrauma patient [7]. The initial diagnosis and management of extremity injury is discussed in detail elsewhere. (See "Severe upper extremity injury in the adult patient".)

Upper extremity arterial injury may also result from arterial access procedures. Inadvertent cannulation of the subclavian artery, rather than vein, can result in life-threatening bleeding if the device is removed in uncontrolled circumstances, particularly among those who are anticoagulated. Brachial artery injury may also be related to percutaneous aortic or mesenteric intervention or inadvertent peripherally inserted central catheter (PICC) line placement. Radial arterial cannulation for blood pressure monitoring and the increasingly common use of radial artery access for percutaneous coronary interventions can also lead to injury; however, for most people, occlusion of the radial artery does not typically jeopardize the hand or fingers because the ulnar artery is usually the dominant source of blood flow to the hand [8,9]. (See "Vascular complications of central venous access and their management in adults" and "Periprocedural complications of percutaneous coronary intervention" and "Access-related complications of percutaneous access for diagnostic or interventional procedures".)

●Atherosclerotic occlusive lesions – Subclavian atherosclerotic disease is often asymptomatic but can present with ischemic symptoms due to embolization or vascular steal (eg, subclavian steal, coronary steal in the presence of a patent left internal mammary artery [LIMA] to the left anterior descending coronary artery [LAD] graft, hemodialysis access-related steal) (image 1) [10-14]. (See "Upper extremity atherosclerotic disease" and "Subclavian steal syndrome" and "Hemodialysis access-induced distal ischemia".)

●Arterial thoracic outlet syndrome – Symptoms of extremity ischemia due to arterial compression are the least common presentation of thoracic outlet syndrome. Thoracic outlet decompression and arterial reconstruction may be indicated for those with severe ischemia or aneurysmal degeneration of the subclavian artery. (See "Overview of thoracic outlet syndromes", section on 'Arterial TOS'.)

●Upper extremity aneurysm – Arterial aneurysms (true, pseudoaneurysm) of the upper extremity arteries are uncommon [15-21]. They are often related to traumatic injury, and the average age of the patient tends to be much lower than that of the atherosclerotic patients. As an example, repetitive trauma to the relatively superficial vessels in the hand can lead to ulnar artery aneurysm (ie, hypothenar hammer syndrome). Alternatively, upper extremity aneurysm may result from cannulation of the radial artery for monitoring purposes. The presentation may be a notable thin-walled pulsatile mass or neurologic symptoms from nerve compression in a confined space. Treatment may be guided by symptoms, diameter, and potential for distal emboli. The diagnosis and treatment decisions may be guided by physical exam, duplex ultrasound, or arteriography to define the adequacy of collateral circulation. The choice to ligate or use vein graft reconstruction is dependent upon adequacy of perfusion of the hand and maturity of collaterals. More often than not, the involved vessel is reconstructed. (See "Overview of aneurysmal disease of the aortic arch branches or upper extremity arteries in adults".)

●Subclavian coverage for thoracic aortic aneurysm (TAA) repair – Preplanned subclavian artery coverage in association with TAA endovascular repair occurs in approximately 40 percent of cases and may lead to ischemic symptoms requiring upper extremity revascularization [22-24]. (See "Endovascular repair of the thoracic aorta", section on 'Arch vessel bypass'.)

●Other occlusive lesions – Other less common disease entities that may lead to aortic arch vessel occlusion include giant cell arteritis, Takayasu's disease, and sclerotic arteritis [25]. (See "Treatment of Takayasu arteritis", section on 'Revascularization' and "Treatment of giant cell arteritis", section on 'Patients with large vessel involvement'.)

VASCULAR ANATOMY — The subclavian arteries provide blood flow to the upper extremities. On the left, the subclavian artery originates directly from the aortic arch distal to the left common carotid artery. On the right, blood flows first through the innominate (brachiocephalic) artery, which divides into the right common carotid artery and right subclavian artery (figure 2). The anatomy of the aortic arch can vary (figure 3) and may include an anomalous origin of the subclavian arteries. (See "Vascular rings and slings" and "Approach to the evaluation of dysphagia in adults", section on 'Cardiovascular abnormalities'.)

The vertebral arteries most often arise bilaterally as the first branch of the subclavian artery. In approximately 6 percent of patients, the vertebral artery, especially the left, may originate directly from the aortic arch [26]. The subclavian artery passes over the first rib posterior to the anterior scalene muscle (figure 4) and becomes the axillary artery at the lateral margin of the first rib. The first part of the axillary artery is close to the chest wall and medial to the pectoralis minor muscle. The second part of the axillary artery is located directly beneath the pectoralis minor, and the third portion is just lateral to the pectoralis minor. The axillary artery becomes the brachial artery (figure 5) at the lower margin of the teres major muscle. The brachial artery passes between the biceps and triceps muscles accompanied by the ulnar and median nerves adjacent to the humerus and supplies the soft tissues of the arm. In the antecubital fossa, the brachial artery divides (figure 1) into the radial, interosseus, and ulnar arteries to supply the soft tissues of the forearm. Distally at the wrist, the ulnar artery and radial artery supply the hand (figure 6).

The circulation around the shoulder is usually sufficient such that flow around a focal area of chronic stenosis in the subclavian artery is well compensated through a rich network of collaterals (figure 7). When the proximal subclavian artery is occluded, blood flow is maintained to the arm via connections between the superior and inferior thyroid arteries; vertebral arteries, intercostals, superior epigastric, and internal thoracic arteries; profunda cervicis and descending branch of the occipital artery; scapular branches of the thyrocervical trunk and the branches of the axillary artery; and the thoracic branches of the axillary artery with the aortic intercostals [27]. The collateral circulation may be sufficient so that the lesion is detected only through routine blood pressure measurements; it would not be surprising to see a difference of 30 to 40 mmHg between the two arm systolic pressures. (See 'Vascular evaluation' below.)

The upper extremity veins are divided into the superficial and deep systems. The deep veins of the upper extremity include the paired ulnar, radial, and interosseous veins in the forearm; paired brachial veins of the upper arm; and axillary vein. The axillary vein becomes the subclavian vein at the lower border of the teres major muscle (figure 8). The main superficial veins of the upper extremity include the cephalic, basilic, median antebrachial, median antecubital, and accessory cephalic veins (figure 9). These superficial upper extremity veins serve as the mainstay for arteriovenous access creation in the dialysis-dependent patient.

VASCULAR EVALUATION — For patients with upper extremity ischemia with indications for emergency revascularization, a bedside wrist-brachial index should suffice to document the deficit prior to vascular intervention. Under elective circumstances, the relationship between symptoms and suspected arterial stenosis/occlusion can be confirmed with noninvasive upper extremity physiologic studies. (See "Noninvasive diagnosis of upper and lower extremity arterial disease", section on 'Upper extremity segmental pressures' and "Noninvasive diagnosis of upper and lower extremity arterial disease", section on 'Wrist-brachial index'.)

Arterial imaging should be performed prior to revascularization to confirm the location of the lesion and aid in preoperative planning. The images may be obtained intraoperatively in a hybrid room with radiographic capabilities. Although advanced imaging using multidetector computed tomographic (CT) angiography may be sufficient for imaging of the proximal upper extremity vasculature, digital subtraction arteriography is superior for imaging the distal upper extremity vessels. The use of CT angiography is widespread for evaluating potential vascular injuries in otherwise previously healthy patients [28]. The absence of preexisting atherosclerotic calcifications will demonstrate the flow-limiting lesions with clarity, and the vessels may often be followed easily to the wrist. Below that point, the amount of contrast makes it difficult to determine adequacy of flow into the digits. (See "Noninvasive diagnosis of upper and lower extremity arterial disease".)

For patients with cerebral (anterior and posterior circulation) and/or upper extremity symptoms such as embolization or ischemia, the aortic arch branch (ie, great vessels, supraaortic) vessels should also be imaged. A chest and neck CT angiogram provides excellent views of the origins of the great vessels as they arise from the arch and can completely evaluate their course in the neck. Cerebral imaging can be performed if there is a suspicion of a more distal lesion or neurologic insult.

Duplex ultrasound has an established role in the evaluation of the extracranial carotid arteries. A thorough study of the carotids should include a velocity and directional evaluation of the vertebral arteries and may detect a more proximal occlusion. Duplex evaluation of the upper extremity arteries and veins in the thoracic outlet is also quite helpful. Naturally, the more proximal innominate artery dives deeper behind the sternum, as does the more proximal left subclavian artery behind the left sternoclavicular joint, but occlusive disease may be indirectly determined by noting dampening of the visualized velocity waveform [29].

APPROACH TO COMMON LESIONS

Embolization — The approach to treatment of upper extremity embolization depends upon the source of embolization and severity of ischemic symptoms. For some patients, as with acute lower extremity ischemia, catheter-directed thrombolysis may be an appropriate first course of action [30]. However, surgical embolectomy can quickly restore upper extremity perfusion, particularly if emboli are focal. (See 'Embolectomy' below.)

Acute traumatic injury — Injuries to the aortic arch (ie, supraaortic trunks)/thoracic outlet (subclavian and proximal axillary arteries) can be particularly challenging because of potential difficulties in obtaining proximal exposure. The surgeon should always anticipate the need for more proximal control in the trauma patient with upper extremity vascular injury and include the chest in the sterile field. Prosthetic grafts are preferred for proximal injuries. (See 'Innominate/proximal subclavian' below and 'Aortic arch branch reconstruction' below.)

More distal injuries are best managed by primary arterial repair or interposition grafting using autogenous vein. Autologous vein bypass may be necessary to bypass a large zone of arterial injury, which may require the use of temporizing shunts (picture 1). With the recognition of the sequelae of vein ligation, repair of major venous injuries is recommended in patients who are hemodynamically stable. (See 'Local repair' below and 'Venous injury' below.)

Proximal occlusive lesions — Chronic upper extremity ischemia due to aortic arch (ie, supraaortic trunk) lesions can be effectively treated with angioplasty and stenting and/or a surgical bypass. For supraaortic reconstruction or extra-anatomic bypass, prosthetic graft is preferred. Surgery is more durable and should be considered the first line of treatment for good surgical risk patients, but good outcomes have been reported using endovascular techniques [31-39]. For subclavian artery revascularization, both open and endovascular therapy are safe and effective, but surgical bypass is more durable [40]. Angioplasty alone has inferior outcomes compared with angioplasty and stenting, particularly when recanalizing occlusive subclavian lesions. In a review of 114 patients, assisted primary patency and freedom from recurrent symptoms were worse in patients presenting with arm ischemia compared with those presenting with cardiac or vertebrobasilar insufficiency at five years [41]. Endovascular stent-graft repair has been used for repair of aneurysms and both penetrating and blunt injuries to the axillary and distal subclavian arteries with good results. (See 'Aortic arch branch reconstruction' below and 'Endovascular repair' below.)

Distal occlusive lesions — Chronic upper extremity ischemia due to infraaxillary arterial lesions are best treated with surgical bypass. There are very few reports on the effectiveness of angioplasty for the more distal upper extremity arterial lesions. Autologous vein is the preferred conduit for more distal reconstructions and in the presence of a contaminated field or a large zone of injury. The vein conduit should be harvested from an uninjured extremity. (See 'Upper extremity bypass' below.)

Aortic arch debranching — For patients who will undergo endovascular repair of the thoracic aorta for management of thoracic aortic aneurysm/dissection, coverage of the left subclavian artery may be necessary to obtain proximal endograft fixation. Extra-anatomic upper extremity revascularization may be performed prior to endovascular repair, or only as needed postoperatively if the patient develops symptoms. (See "Endovascular repair of the thoracic aorta", section on 'Need for debranching procedures'.)

OPEN SURGICAL REPAIR

Arterial exposure and control — Exposure of the various arterial segments in the upper extremity is as follows [42].

Innominate/proximal subclavian — In general, the aortic arch (ie, supraaortic) vessels (except for the left subclavian artery) can be accessed through a median sternotomy (figure 10). Although it is possible to dissect out the proximal left subclavian artery from the midline chest approach, this requires careful elevation of the left chest wall and dissection along the anterior portion of the aortic arch. Care must be taken to identify and avoid injury to the left vagus and recurrent nerves in this location.

The midline sternotomy incision is made from the sternal notch to the xiphoid. At each end of the sternum, the dissection is performed bluntly, exposing the sternal notch and the subxiphoid area. It is critically important to take down the ligament at the top of the suprasternal notch with the cautery to allow access to the anterior mediastinum. There is sufficient strap muscle beneath to allow this to be divided without injury to the deeper structures. With ventilation briefly discontinued, the sternum is divided using a sternal saw or, alternatively, with a Lebsche knife, and then retracted using a Finochietto retractor. When the sternal saw is used, the saw must be drawn through the sternum with a single smooth motion and avoiding pulling up on the saw; the upward pull often will overcome the torque on the blade and the saw will grind to a halt. The left innominate vein beneath the thymus is a key landmark to further identify the arch vessels, and, if obscured by hematoma, opening the pericardium will help to identify the aortic root. By tracing the aorta as it ascends from the heart, the great vessels can be safely identified. The takeoff of the innominate artery may occasionally be identified within the pericardium, but the other vessels cannot, as they are not within the pericardial sac. A partial or complete median sternotomy may be combined with a left or right supraclavicular incision to facilitate exposure of the proximal vessels (see "trap door" in the next paragraph). On occasion, if a partial sternotomy is performed, a horizontal incision is made in the sternum at the level of the third or fourth interspace and usually requires division of the mammary vessels. This allows the upper sternum to slide open to the side of the horizontal incision.

Exposure of the proximal left subclavian requires an anterior thoracotomy, the incision for which is made in the third interspace of the anterior surface of the left chest (figure 11). The intercostal musculature is divided on the cephalad aspect of the rib to avoid injury to the intercostal neurovascular bundle. After entering the left chest, a Finochietto retractor is inserted between the ribs to improve exposure (figure 12). By retracting the uninflated lung, the aortic arch and proximal left subclavian can be identified after dissecting the overlying visceral pleura. The combination of the partial median sternotomy, the left supraclavicular incision, and the third interspace anterolateral thoracic incision creates the so-called open book or "trap door" incision (figure 13). For trauma, this approach is almost exclusively used for exposure of the proximal left subclavian artery, as the right proximal subclavian artery is easily seen in the medial aspect of the right supraclavicular incision. A right-sided trap door incision is used for removal of right-sided Pancoast tumors encroaching on the vasculature.

Carotid/mid-to-distal subclavian — Exposure of the proximal carotid or mid-to-distal subclavian (right or left) can be accomplished through a supraclavicular incision (figure 11 and picture 2). If exposure of the subclavian artery is inadequate, the clavicle can be resected (figure 14), but this is uncommonly needed. The supraclavicular incision is made approximately 1 cm above the clavicle, from the clavicular head and extending laterally. The platysma is incised and the external jugular vein is divided. The clavicular head of the sternocleidomastoid is divided, exposing the carotid sheath beneath. After incising the sheath, the internal jugular vein is dissected from the carotid and retracted. The vagus nerve and sympathetic chain are typically located posterolaterally in the carotid sheath and must be preserved.

When the subclavian artery is exposed using the supraclavicular incision, the omohyoid muscle is divided along with the sternocleidomastoid muscle and external jugular vein. The fascia and supraclavicular fat pad are incised medially and dissected laterally. On the left, the thoracic duct should be identified, ligated (or clipped), and divided if there is suspicion that it has been injured during the dissection. Specific attention to this area is required before closing to ensure that there is no lymph welling up in the field. The anterior scalene muscle lies between the subclavian vein and artery and inserts on a protuberance on the superior surface of the first rib (figure 15). The phrenic nerve lies on top of the anterior scalene muscle and characteristically moves from lateral to medial across the muscle surface as it moves downward into the chest, and it should be identified and preserved. Once the phrenic nerve has been isolated, the anterior scalene muscle is divided to expose the underlying subclavian artery.

Axillary — Exposure of the proximal and midaxillary artery can be achieved through an infraclavicular incision (figure 11). The incision is placed 2 cm below the clavicle over the lateral aspect of the deltopectoral groove. The soft tissue and clavipectoral fascia are divided, and the pectoralis major muscle is split and retracted (picture 3). The pectoralis minor muscle serves as the marker for the second part of the artery and may need to be divided for optimal exposure. The subclavian vein and artery lie under the clavicle. The vein must be mobilized and retracted to expose the artery.

Brachial — The brachial artery can be exposed anywhere along its length (picture 1 and picture 4). Above the elbow, an axial incision is made in the groove between the biceps and triceps, taking care to avoid the more superficial basilic vein. The neurovascular sheath is incised to expose the artery with retraction of the median and ulnar nerves as needed.

At the antecubital fossa, an S-shaped incision is placed medially in the groove in the arm and carried transversely across the elbow crease and then inferiorly on the lateral forearm. The subcutaneous tissue is divided, and the basilic vein is exposed and retracted medially. The brachial artery is exposed with division of the bicipital aponeurosis, which appears much like a nerve fiber with magnification, but it is more like a sheet and is directed almost perpendicular to and more superficial to the expected course of the median nerve.

Radial/ulnar — The radial and ulnar arteries can be exposed at the elbow level by extending the distal lateral portion of the above-described S-shaped incision and retracting the pronator teres medially and the brachioradialis laterally. The radial branch follows the brachioradialis muscle. The ulnar branch is deep to the pronator teres muscle.

More distally, the radial artery can be exposed using a longitudinal incision placed over the radius, just lateral to the flexor carpi radialis tendon, starting at the wrist and extending proximally. After dividing the subcutaneous tissue and deep fascia, the artery is identified between the brachioradialis tendon laterally and the flexor carpi radialis tendon medially.

The ulnar artery can be exposed distally via a longitudinal incision placed over the ulna, just medial to the flexor carpi ulnaris tendon, starting at the wrist and extending proximally. Similarly, once the subcutaneous tissue and deep fascia are incised, the ulnar artery can be identified adjacent the ulnar nerve medial to the flexor carpi ulnaris tendon.

Conduit for bypass — The conduit chosen for upper extremity revascularization depends upon the bypass location. For aortic arch (ie, supraaortic) vessel reconstruction or extra-anatomic bypass, prosthetic graft is preferred [43-45].

Autologous vein is the preferred conduit for more distal reconstructions and in the presence of a contaminated field or a large zone of injury [46]. Autologous veins are suitable for targets as distal as the radial and ulnar arteries. An arterial conduit (eg, radial artery) is an alternative for distal upper extremity revascularization [47,48]. However, this is not commonly used because of the high success rate with great saphenous vein.

The vein conduit should be harvested from an uninjured extremity. The upper extremity ipsilateral veins in an upper extremity vascular injury should be preserved to maximize venous outflow from the injured limb. Rather than harvest contralateral arm vein, most surgeons will harvest the great saphenous vein from the lower extremity, which tends to be more thick-walled and larger in diameter at the groin compared with arm vein. This may serve as a better size match to the injured artery, and the saphenous vein is more easily harvested than the thinner-walled upper extremity veins, which are also are known to be prone to vasospasm. In the event there is insufficient saphenous vein, contralateral arm vein can be used. Harvesting the arm and forearm cephalic vein from the deltoid groove to the wrist can provide a long conduit if needed.

Tunneling the bypass conduit should generally be performed in a subcutaneous fashion. This includes preclavicular tunneling for grafts originating from the distal subclavian or axillary artery [46]. In-situ bypass positioning can also be considered [49].

Embolectomy — Arterial embolectomy may be a primary procedure (embolism from cardiac source) or used in conjunction with other arterial repairs (eg, trauma, aneurysm repair) [5].

For primary embolectomy, arterial access for upper extremity embolectomy is typically obtained via the distal brachial artery. A curvilinear incision over the antecubital fossa will provide the necessary access. A Fogarty balloon embolectomy catheter can be used to perform embolectomy proximally to the aortic arch and distally to the palmar arch. A 3 or 4 French (Fr) embolectomy catheter should be suitable to reestablish proximal inflow at the brachial artery level, and a 3 Fr will be adequate for clearing the distal circulation. Postprocedure angiography is not routinely needed unless there is inadequate reperfusion and persistent ischemia so as to provide more accurate information as to the source.

Local repair — Local procedures (direct repair, patch angioplasty, interposition graft) are commonly used to manage traumatic injuries, particularly penetrating trauma. Short-segment interposition grafting may also be appropriate for the repair of focal arterial aneurysms. Focal arterial disease due to atherosclerosis is more commonly managed using endovascular techniques. (See 'Endovascular repair' below.)

Arterial injury — Some injuries may not exhibit active bleeding from the wound due to vasospasm at the site of injury. If there is no active bleeding, exposure of the underlying vessels can be direct; however, there should be a low threshold to make a separate, more proximal incision for arterial control.

Penetrating arterial injuries from knives, glass, or other sharp objects are typically low-energy wounds, short in length, and typically amenable to direct repair or patch angioplasty. Stab injuries that are more extensive in length should be repaired using a short interposition vein graft connecting two segments of grossly normal arterial wall. On occasion, a tangential injury will allow debridement of the arterial wall followed by an autologous patch repair using saphenous vein.

Gunshot wounds with a higher kinetic energy and therefore greater regional tissue injury often produce arterial injuries that are longer in length and are associated with more extensive soft tissue and bony injuries. After adequate exposure and mobilization of the affected segment, any grossly abnormal arterial wall tissue should be debrided (picture 5). After adequate mobilization, primary repair may be possible, provided there will be no undue tension on the arterial anastomosis. However, in the majority of cases of vascular injury from a gunshot wound, there is a significant segment of artery missing following debridement, such that an interposition graft will be required.

For the small subset of patients in whom the arterial supply to the hand is dependent upon the radial artery due to an incomplete palmar arch, distal revascularization for radial artery injury (ie, catheterization, penetrating trauma) may be necessary, if local repair cannot be achieved [8,9].

Venous injury — In the past, ligation for venous injuries was common practice; however, the recognition of the sequelae of vein ligation and resulting venous stasis led in a change in practice. In one animal study, arterial flow into the canine hind limb was reduced by 40 percent when the ipsilateral common femoral vein is ligated [50]. Repair of major venous injuries in patients who are hemodynamically stable is the accepted standard. However, major venous injuries can be ligated in life-threatening situations. If the named vein is a paired vein, such as a brachial vein, then ligation of one of the veins is well tolerated. An alternative is the use of a short plastic shunt to maintain flow as a temporizing measure. Once the patient is stabilized, the shunt can be removed and the vein reconstructed.

Arterial bypass

Aortic arch branch reconstruction — Open surgical bypass of aortic arch and branch lesions has proven long-term success [51-53]. Endovascular repair is limited to case reports, and the results are limited by lack of long-term follow-up [54].

Open repair often only requires temporary partial occlusion of the aorta with a side-biting clamp to perform the proximal anastomosis but is still associated with significant morbidity and mortality related to the need for midline sternotomy. Nevertheless, open surgical bypass remains the standard for innominate revascularization in good-risk surgical patients who have no calcification in the ascending aorta that would otherwise preclude placement of the clamp. The bypass originates from the ascending aorta, and the configuration of the repair depends upon the number of vessels to be revascularized (figure 16). Prosthetic grafts have proven their superiority compared with vein grafts for this particular anatomic location [43-45].

Extra-anatomic bypass — Extra-anatomic bypass reduces the morbidity associated with in-line reconstruction [55]. Options for extra-anatomic bypass include carotid-subclavian/axillary bypass, carotid transposition [56], subclavian-subclavian, and axillo-axillary [57]. Among these, the carotid-subclavian bypass and carotid-subclavian transposition are more commonly used to treat proximal subclavian artery occlusion with ischemia of the upper extremity.

Carotid-subclavian/axillary bypass — Extra-anatomic revascularization is the most common form of surgical correction for symptomatic subclavian artery stenosis (picture 6). Revascularization can be performed either as a bypass to, or transposition of, the subclavian artery (figure 17).

Carotid-subclavian bypass is typically used to manage symptomatic subclavian steal syndrome with a subclavian or innominate lesion that is not amenable to endovascular intervention [12,13]. Carotid-subclavian or axillary bypass is also appropriate for injuries of the more proximal vessels causing ischemia but not associated with ongoing hemorrhage. Extra-anatomic revascularization may also be needed following thoracic endovascular repair that covers the subclavian artery [58]. For patients with patent inferior mammary artery after coronary artery bypass grafting, carotid-subclavian bypass is preferred to allow continuous blood flow through the diseased subclavian artery while the bypass is completed.

Overall patency rates for these extra-anatomic procedures are excellent. In one review of 287 consecutive carotid subclavian bypasses, primary patency was 95 percent at 5 years, 88 percent at 10 years, and 86 percent at 15 years [12]. In a separate study, patency at five years was significantly higher for procedures using the common carotid artery as the donor vessel compared with those using the contralateral subclavian or axillary arteries (83 versus 46 percent) [59].

Carotid-carotid bypass — In the event that there is no other suitable vessel to serve as inflow to a diseased common carotid artery other than the contralateral carotid artery, a carotid-carotid bypass with prosthetic material will be necessary [60].

To perform a carotid-carotid bypass, both common carotid arteries are exposed through the usual anterior sternocleidomastoid approach. The retropharyngeal space is bluntly dissected from each side to meet in the midline behind the pharynx but superficial to the anterior longitudinal ligament of the spine. This deep positioning of the bypass graft prevents erosion of the skin and protects the graft from any possible contamination from a future tracheostomy [61]. The inflow carotid artery is controlled proximally and distally, and the end-to-side graft to carotid artery anastomosis is performed. The graft is flushed and then clamped as prograde carotid flow is restored and the graft is passed through the retropharyngeal space. The recipient common carotid artery is then clamped, and end of graft-to-side of carotid procedure is performed. After appropriate flushing, prograde flow is restored to the target carotid artery. The initial reports in the 1990s demonstrated no deaths and a stroke rate of 6.2 percent. A patency rate as high as 94 percent at five years has been reported [62].

Carotid-contralateral subclavian bypass — In the event that there is a symptomatic proximal subclavian occlusion and neither the ipsilateral carotid artery nor contralateral subclavian are optimal donor vessels, then the contralateral carotid artery can be used. In this case, the graft is sutured to the target subclavian artery first either as an end-to-side or an end-to-end (as in subclavian transposition) and then tunneled in the retropharyngeal space to the side of the contralateral donor carotid artery (as in a carotid-carotid bypass).

Upper extremity bypass — Many of the general principles used to perform arterial bypass in the lower extremity can also be applied to the revascularization of more distal lesions of the upper extremity. (See "Lower extremity surgical bypass techniques".)

Surgical revascularization should be performed using inflow from a patent vessel that receives in-line flow from the aorta to a distal "target" that should provide direct, in-line flow to the hand. The inflow can be provided by the subclavian, axillary, or brachial artery or alternatively by the ipsilateral common carotid artery, when necessary. The exposures for these vessels, including infraclavicular exposure to the axillary artery; mid-arm exposure of the brachial artery; and antecubital fossa exposure to the distal brachial, proximal radial, and proximal ulnar arteries, are described above [42]. (See 'Arterial exposure and control' above.)

Palmar artery bypasses from the distal forearm to the palmar arch using autogenous vein grafts have been successful for relief of digital ischemia. Most reports detailing outcomes exist in small numbers of patients with limited follow-up [8,9].

ENDOVASCULAR REPAIR — The endovascular approach has gained popularity for patients deemed too ill for open surgery and for those with iatrogenic catheter-induced arterial injuries.

Arterial access — Endovascular revascularization can be accomplished from a femoral or brachial artery approach. Arm access provides better pushability and stability, which is crucial when recanalizing occluded upper extremity vessels. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures".)

Embolic protection — With an endovascular approach, distal embolization is possible during manipulation of the diseased vessel. With innominate lesions, it is advisable to place an embolic protection device (EPD) in the right internal carotid. EPDs are described elsewhere.

If EPD deployment is not possible, we prefer primary stenting with no predilation to minimize the risk of distal embolization. Other adjunctive procedures have been described in addition to placing a filter protection device [63,64]. One example is creating reversal of flow in the vertebral artery by injecting vasodilator in the arm circulation.

Angioplasty/stenting — Observational studies suggest that percutaneous transluminal angioplasty and stenting is safe in patients with appropriate anatomy (short proximal stenosis or occlusion). The combined stroke and death rate related to percutaneous intervention to treat upper extremity disease was 3.6 percent in one study [65]. Complications include stent thrombosis, restenosis, and stent fracture (picture 7) [65-67].

Good outcomes have been reported using endovascular techniques in treatment of lesions of the aortic arch (ie, supraaortic) vessels (image 2) [54,68-83], but there are very few reports on the effectiveness of angioplasty for the more distal upper extremity arterial lesions [2,3,84].

Immediate technical success occurs in more than 93 percent of patients, with failures usually related to an inability to cross an occlusive lesion [85,86]. Five-year primary patency rates are approximately 85 percent [86]. Sustained resolution of ischemic symptoms is observed in most patients (>95 percent) [85-88].

Angioplasty alone has inferior outcomes compared with angioplasty and stenting, particularly when recanalizing occlusive subclavian lesions [65,83,89]. A systematic review and meta-analysis comparing angioplasty alone with angioplasty and stenting for subclavian artery stenosis found a significantly higher risk of subsequent events for angioplasty alone compared with angioplasty and stenting at one year (odds ratio 2.37, 95% CI 1.32-4.26) [90]. A retrospective study of 42 patients treated with angioplasty and stenting for coronary subclavian steal syndrome found that the rate of restenosis was higher in patients with a continuous (compared with intermittent) subclavian and coronary steal (41 and 7 percent) [91].

Symptoms due to significant (>70 percent) recurrent stenosis or obstruction occur in approximately 10 percent of patients and are typically treated with repeat angioplasty; however, surgery may be required in up to 5 percent of patients [65]. Some risk factors for subclavian in-stent stenosis include younger age, smoking with history of chronic obstructive pulmonary disease, or baseline vessel diameter ≤7 mm [92]. A meta-analysis comparing open surgery with endovascular repair for subclavian atherosclerotic disease showed favorable early outcomes for both techniques, and no significant differences in survival [31]. While open repair had a better long-term patency, there were no significant differences symptom recurrence.

Stent-grafting — Open surgery for subclavian artery aneurysm has been the standard and provides a durable long-term repair. However, as with aneurysms at other sites, endovascular stent-grafting has been increasingly used to exclude the aneurysm from the circulation [18-21]. Subclavian artery aneurysms can occur proximally, associated with atherosclerosis, or more distally due to injury (eg, repetitive injury as with thoracic outlet syndrome). Each of these segments has anatomic features that make stent-graft placement challenging, and motion of the shoulder can lead to graft compression with the potential for endograft fracture.

Endovascular stent-graft repair (figure 18) has also been applied to treatment of penetrating [93] or blunt [94] injuries to the axillary and distal subclavian arteries with good results. A review of 223 patients with subclavian and axillary injuries from 11 trauma centers showed an excellent limb salvage rate of 97 percent but a 10 percent in-hospital mortality related to cardiac (38 percent), brain (21 percent), hemorrhage (21 percent), multisystem organ failure (17 percent), and drug-related (4 percent) causes. The authors of the review also emphasized the importance early control of bleeding, typically using open exposure but noting increasing use of hybrid techniques (eg, balloon occlusion) [95].

ADJUNCTIVE PROCEDURES

Fasciotomy — The possibility of developing compartment syndrome should be considered in all patients presenting with acute upper extremity ischemia. Anticipation for compartment syndrome should be heightened in the presence of systemic hypotension, crush injury to the arm, and combined arterial and venous injury, as well as venous injury necessitating ligation. Compartment syndrome in the upper extremity most often occurs in the forearm but may also occur in the hand and in the upper arm. Three-compartment forearm fasciotomies should be performed at the time of revascularization in patients who exhibit profound acute ischemia (ie, little or no residual motor deficit, complete sensory loss) (picture 8). For other patients, fasciotomy can be performed as needed, if signs of compartment syndrome develop. (See "Acute compartment syndrome of the extremities" and "Surgical reconstruction of the upper extremity".)

Debridement/amputation — Following revascularization, the ischemic extremity can be managed expectantly; soft tissue defects that do not improve may require debridement, partial finger amputation, or skin grafting. In the presence of good limb perfusion and in the absence of infection, there usually is no urgency to remove marginal or dying tissue. In many cases it is wise to wait and see so that the tissue will clearly demarcate and minimize ultimate tissue loss. (See "Basic principles of wound management" and "Skin autografting" and "Upper extremity amputation".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Occlusive carotid, aortic, renal, mesenteric, and peripheral atherosclerotic disease" and "Society guideline links: Thoracic trauma".)

SUMMARY AND RECOMMENDATIONS

●Arterial disorders of the upper extremity that require revascularization are much less common than those of the lower extremity. The main indications for upper extremity revascularization are acute limb ischemia typically due to traumatic injury or cardiogenic emboli, and chronic extremity ischemic pain or tissue loss due to arterial stenosis, most commonly atherosclerotic disease but also from the late sequelae of traumatic injuries. Other less common etiologies include upper extremity aneurysmal disease, arterial thoracic outlet syndrome, and the need for subclavian coverage to accommodate thoracic endovascular repair, among others. (See 'Indications' above.)

●Under elective circumstances, the relationship between symptoms and suspected arterial stenosis/occlusion should be confirmed with noninvasive upper extremity physiologic studies. For those with acute upper extremity ischemia, a bedside wrist-brachial index should suffice to document the deficit prior to emergent revascularization. Arterial imaging should be performed prior to revascularization to confirm the location of the lesion. Multidetector computed tomographic (CT) angiography is sufficient for imaging the proximal upper extremity vasculature; however, digital subtraction arteriography is superior for imaging the distal upper extremity vessels. Vascular imaging should also include the aortic arch branch vessels (ie, supraaortic) and neck vessels. (See 'Vascular evaluation' above.)

●Short-segment traumatic injuries are best managed with primary arterial repair or interposition grafting using autogenous vein. Vein bypass may be necessary to manage a more extensive injury. Repair of major venous injuries is recommended for patients who are hemodynamically stable. (See 'Local repair' above and 'Venous injury' above and "Severe lower extremity injury in the adult patient", section on 'Management approach'.)

●Symptomatic lesions involving the aortic arch (ie, supraaortic) vessels are most effectively treated with open surgical bypass or angioplasty/stenting. Prosthetic bypass grafting is very durable and should be considered the first-line treatment for good surgical risk patients. If surgical repair is not an option, angioplasty with stenting can be performed for occlusive lesions. For aneurysm (true or pseudoaneurysm), endovascular stent-graft repair is an alternative. (See 'Innominate/proximal subclavian' above and 'Aortic arch branch reconstruction' above and 'Endovascular repair' above.)

●Chronic upper extremity ischemia due to infraaxillary arterial occlusive disease is best managed with surgical bypass. Autologous vein is the preferred conduit for more distal reconstructions and in the presence of a contaminated field or a large zone of injury. The vein conduit should be harvested from an uninjured extremity. (See 'Upper extremity bypass' above.)

●The possibility of developing compartment syndrome should be considered in all cases of acute limb ischemia. Upper extremity fasciotomies can be performed at the time of revascularization if ischemia is profound, or as needed. (See 'Fasciotomy' above.)

●Following revascularization, the patient may require soft tissue debridement or grafting to manage tissue loss. Watchful waiting allows tissue to clearly demarcate and minimizes tissue loss. (See 'Debridement/amputation' above.)