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Anaesthesia for vascular surgery

of the upper limb


2A03, 3A05
Julie Lewis MB ChB FRCA
Richard Telford BSc (Hons) MB BS FRCA

Key points Vascular surgery on the upper limb is much less shoulder. It may simply present as a noticeable
common than on the lower extremity. Upper difference in the blood pressure recorded in
Vascular surgery on the
limb ischaemia is much less common than lower both arms. Exercise-induced claudication may
upper limb is much less
common than on the lower limb ischaemia; in part this is because of the develop in more advanced disease. Emboliza-
limb—in part this is because presence of a good collateral circulation around tion from atherosclerotic plaques may lead to
of the well-developed the shoulder. Acute upper limb ischaemia is a acute upper limb ischaemia or digital gangrene.
collateral circulation around real emergency as the ischaemic tolerance of Patients with upper limb ischaemia invari-
the shoulder. upper limb is much less than the lower limb. In ably have disease in other large arteries, predis-
Many patients presenting for this article we will discuss the management of posing them to an increased risk of myocardial
vascular surgery on the acute and chronic upper limb ischaemia, thoracic infarction, stroke, and death. They benefit from
upper limb have severe outlet syndrome (TOS), and vascular access secondary prevention measures such as control
atherosclerotic disease. surgery for renal dialysis. of hypertension, lipid modification, administra-
Patients presenting for tion of antiplatelet drugs (aspirin, clopidogrel, or
surgery for thoracic outlet both), smoking cessation, and glycaemic
Anatomy of the arterial supply
syndrome are often younger control. Asymptomatic patients do not require
to the upper limb
and have a lower incidence surgical intervention.
of co-morbidity. The subclavian arteries supply blood to the Conditions which require surgical interven-
Preoperative assessment is upper extremities. On the left, the subclavian tion are described below.
important; appropriate artery originates directly from the aorta, and on
risk-reducing measures to the right it arises from the bifurcation of the in-
minimize the nominate artery. The anatomy of the aortic arch
Subclavian steal syndrome and coronary
thromboembolic can vary; there may be anomalous origins of the
subclavian steal syndrome
complications of vascular subclavian arteries directly from the arch of The term subclavian steal syndrome was first
disease should be instituted the aorta, or from the common carotid trunk. used in 19611 to describe neurological symp-
where appropriate.
The vertebral arteries arise from the second part toms during or immediately following exercise
of the subclavian artery. The subclavian artery of the ipsilateral arm. Symptoms are caused by
passes over the first rib posterior to the anterior retrograde flow in the vertebral artery associated
Julie Lewis MB ChB FRCA scalene muscle. It becomes the axillary artery at with ipsilateral proximal subclavian artery sten-
Specialty Registrar Anaesthetics the lateral border of the first rib. The axillary osis or occlusion—blood is ‘stolen’ from the
Royal Devon and Exeter Foundation NHS artery becomes the brachial artery at the lower
Trust
posterior cerebral circulation.
Barrack Road margin of teres major muscle and divides into In 1974 Harjola and Valle2 described a
Exeter the radial, interosseus, and ulnar arteries in the patient with proximal subclavian stenosis who
EX2 5DW antecubital fossa.
UK
reported angina after arm exercise after coronary
artery bypass surgery using an ipsilateral intern-
Richard Telford BSc (Hons) MB BS al mammary artery conduit. They used the term
FRCA Chronic upper limb ischaemia
coronary subclavian steal to differentiate it from
Consultant Anaesthetist
Department of Anaesthetics
Aetiology the previously recognized vertebral subclavian
Royal Devon and Exeter Foundation NHS steal. Angina is caused by retrograde flow in the
Trust Although there are numerous causes of upper
internal mammary conduit ‘stealing’ blood from
Barrack Road limb ischaemia (Table 1), atherosclerosis is the
Exeter the heart.
most common cause of upper limb arterial
EX2 5DW
UK disease.
Tel: þ44 013 924 02474 Atherosclerosis of the subclavian artery Clinical presentation
Fax: þ44 013 924 02472 frequently remains asymptomatic because of Muscle cramping as a result of ischaemia may
E-mail: r.telford@nhs.net
(for correspondence) the excellent collateral circulation around the occur in manual workers who perform vigorous
doi:10.1093/bjaceaccp/mkt044 Advance Access publication 3 September, 2013
119 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 14 Number 3 2014
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Anaesthesia for vascular surgery

Table 1 Aetiology of upper limb ischaemia Treatment


Chronic upper limb ischaemia Acute upper limb ischaemia Isolated subclavian stenosis can be treated by endovascular balloon
angioplasty and stenting. Success rates are high, but restenosis rates
Large artery disease Small artery disease
of 6–20% have been reported.3
Atherosclerosis Vasculitis If the subclavian artery is occluded or endovascular repair is un-
Arterial injury Rheumatoid arthritis Atrial fibrillation successful, an extrathoracic carotid-subclavian bypass may be used.
Arterial dissection Systemic lupus erythematosis Post MI (mural thrombus)
Surgical exposure is through a transverse incision at the base of the
Thrombosed aneurysm Scleroderma Paradoxical venous embolus
Atheroembolism Sjogrens syndrome Thoracic dissection neck extending laterally from the sternal notch parallel to the clav-
Thromboembolism Repetitive injury Subclavian artery aneurysm icle. A prosthetic graft is tunnelled and anastomosed end to side to
Arterial fibrodysplasia Vibratory tool arterial injury Iatrogenic
the subclavian artery.
Arterial tumour Hypothenar hammer syndrome
Arteritis Radiation disease Alternatively, subclavian transposition may be performed. The
Repetitive injury Drug related subclavian artery is anastomosed end to side onto the common
TOS Vasopressors
carotid artery. This operation is performed through a transverse inci-
Crutch injury Vasospasm
Raynaud’s disease sion at the base of the neck and has the advantage of not requiring
prosthetic material. The dissection is more extensive—care must be
TOS, thoracic outlet syndrome; MI, myocardial infarction.
taken to avoid injury to the thoracic duct on the left side. Long-term
results of subclavian transposition procedures are similar to those of
carotid-subclavian bypass.
exercise of the arms, often with their arm elevated above their head.
Neurological symptoms are as a result of ischaemia in the posterior
Anaesthetic considerations
cerebral circulation. These rarely progress to cerebral infarction.
A balanced general anaesthetic is required. Patients will usually
Dizziness or vertigo occur commonly (.50%). Visual symptoms
have extensive co-morbidity, and will therefore require careful pre-
may include transient visual loss, double vision, or the sensation that
operative assessment. A valid group and save should be performed.
objects are moving. Transient loss of consciousness may occur.
Large bore i.v. access is mandatory because of the risk of bleeding,
Stenosis or occlusion of the proximal vertebral artery may
as is invasive arterial monitoring which should be inserted on the
produce similar neurological symptoms. Occlusive disease of the
contralateral side. Other investigations depend on patient fitness and
vertebral artery should be considered if posterior circulation symp-
comorbidity.
toms occur with normal blood pressure in the ipsilateral arm
The patient is usually placed in the supine position. The carotid
The most commonly reported cardiac symptom is angina.
artery must be cross-clamped temporarily whilst the anastomosis is
Coronary subclavian steal has been implicated as a cause of congest-
performed. Five thousand units of heparin should be administered i.v.
ive cardiac failure, ischaemic cardiomyopathy, and myocardial
before carotid cross-clamping. The short period of cortical ischaemia
infarction.
is generally well tolerated; the incidence of perioperative stroke is very
low. Carotid shunting is not usually required, but may be considered
Diagnosis in patients with evidence of contralateral carotid disease.
A marked reduction in the blood pressure on the symptomatic After operation the patient must be observed closely for signs of
side is almost invariably found in patients with subclavian steal. bleeding. The peripheral circulation can be monitored using Doppler
A chest X-ray should be performed to look for unusual causes of ultrasonography. It is difficult to measure the blood pressure in the
subclavian stenosis (e.g. a cervical rib). Doppler ultrasonography operative arm, particularly if a carotid-subclavian bypass has been
is most commonly used to diagnose vertebral subclavian steal. It performed.
is important to visualize the ipsilateral carotid artery to look
for isolated stenoses if surgical intervention is planned.
Ultrasonography is not useful to assess flow in the proximal sub- Thoracic outlet syndrome
clavian artery. TOS refers to a cluster of symptoms caused by compression of
Computerized tomography (CT) angiography with contrast gives the neurovascular structures of the upper limb as they pass between
excellent information regarding the nature of the arterial lesion. the first rib and clavicle en route to the axilla. Symptoms depend
This may be advantageous as it does not require direct arterial punc- on the component affected—the brachial plexus, subclavian artery
ture and can be used to plan surgical repair in detail. If endovascular or subclavian vein—giving rise to neurogenic, arterial or venous
treatment is being considered, it may be more appropriate to proceed TOS, respectively.
to conventional angiography as treatment can be performed at
the same time. Magnetic resonance angiography can be used, espe-
Anatomy
cially if there is pre-existing renal dysfunction as the contrast used
is less nephrotoxic. It tends to overestimate the degree of arterial The thoracic outlet refers to the opening through which structures
obstruction. from the neck and thorax enter the upper limbs (Fig. 1). It consists

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Anaesthesia for vascular surgery

Fig 2 Right-sided venography demonstrating subclavian vein thrombosis


(arrow). The typical meniscus is well visualized.

accounts for the majority of cases of TOS. Symptoms reflect the


nerve roots involved. Symptoms do not follow a dermatomal distri-
Fig 1 Anatomy of the thoracic outlet. bution, distinguishing TOS from radicular nerve pathology. Ninety
per cent of cases involve the C8 and T1 nerve roots causing pain
and paraesthesia in an ulnar nerve distribution and wasting of ab-
Table 2 Aetiology of thoracic outlet syndrome ductor pollicis brevis, the hypothenar eminence, and interosseii.
Skeletal factors Congenital soft tissue Acquired soft tissue abnormalities Involvement of C5, C6, and C7 causes pain referred to the upper
abnormalities chest, neck, ear, and outer arm. Radial nerve symptoms can also be
present.
Cervical rib Fibrous bands Post-traumatic fibrous scarring
Elongated C7 transverse Variations in scalene Postoperative scarring Arterial TOS is caused by subclavian artery compression usually
process muscle insertion between a cervical rib or band and scalenus anterior. Subclavian
Exostosis/tumour of the Supernumerary Space-occupying lesions
artery stenosis occurs which may progress to subclavian artery oc-
first rib or clavicle muscles (Pancoast tumour, cysts)
Excess callus formation Inflammation of soft-tissue clusion. Post stenotic dilatation and aneurysm formation may be
after fracture of the seen. Patients often have an occupational or recreational history of
first rib or clavicle
arm overuse (e.g. painters, mechanics, swimmers, and rowers).
Hypertrophic muscles and
repetitive activities (athletes, Distal embolization may occur from mural thrombus producing
especially swimmers) acute brachial ischaemia. The diagnosis is made with a combination
Poor posture and weak muscular
of arteriography, ultrasound, CT, or magnetic resonance imaging.
support
Venous TOS causes swelling and congestion of the arm.
Cyanosis, pain in the arm, and venous distension over the shoulder
and chest may be present. Paraesthesia can occur, but is due to swel-
of the body of T1 posteriorly, the medial borders of the first ribs lat-
ling rather than nerve compression. It can be thrombotic (Paget –
erally and the superior border of the manubrium anteriorly. It trans-
Schrotter syndrome or effort thrombosis) or non-thrombotic.
mits the oesophagus, trachea, thoracic duct, phrenic, vagus and
Thrombotic venous TOS commonly follows strenuous upper body
recurrent laryngeal nerves, sympathetic trunks, common carotid and
exertion whereby repetitive compression of the subclavian vein
subclavian arteries, internal jugular, brachiocephalic and subclavian
between the clavicle and the first rib causes intimal damage, activat-
veins. The brachial plexus emerges between scalenus anterior and
ing the clotting cascade and causing acute venous thrombosis. Ten
scalenus medius, superior to the thoracic outlet, and runs over the
per cent of patients may develop pulmonary emboli. Diagnosis is
first rib into the axilla.
made by venography (Fig. 2).

Aetiology
Treatment
The aetiology of TOS is summarized in Table 2. TOS most com-
monly affects young females aged between 20 and 40 years of age, Management may be surgical or conservative with advice regarding
with a 4:1 female-to-male preponderance. posture, physiotherapy, and multimodal analgesia. Surgical manage-
ment can vary from excision of soft tissue or bony abnormalities
to complex vascular reconstructions sometimes involving bypass
Clinical presentation and diagnosis
grafts.
The clinical features of TOS depend on the structures affected. The first rib may be removed via the transaxillary route in un-
Neurogenic TOS refers to compression of the brachial plexus and complicated arterial and venous TOS. A cervical rib can also be

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Anaesthesia for vascular surgery

removed using the transaxillary approach, but the first rib must be drain. This can necessitate a return to theatre for video-assisted clot
removed first in order to gain safe access. The supraclavicular ap- evacuation, or thoracotomy in severe cases.
proach is necessary for complicated arterial cases (e.g. subclavian Patients are usually discharged 2– 3 days after operation and
aneurysms), and cases of neurogenic TOS which require exploration advised to maintain shoulder and cervical spine mobility but avoid
of the brachial plexus or removal of a cervical rib or band. The first strenuous exercise or loading until physiotherapy follow-up.
rib can also be removed by the supraclavicular route.

Acute upper limb ischaemia


Neurogenic
Physiotherapy and multimodal analgesic techniques play an import- Acute upper limb ischaemia is a surgical emergency because the is-
ant role in the management of neurogenic TOS. Surgical exploration chaemic tolerance of the upper limb is much less than the lower
of the brachial plexus via a supraclavicular approach may be consid- limb; tissue loss can occur rapidly.
ered, especially if abnormal anatomy is thought to be the cause of
nerve compression or there is evidence of neurological deterioration
such as muscle weakness or wasting. Aetiology and presentation
Acute ischaemia in the upper limb is usually caused by emboli.
Arterial Occasionally, the arterial supply to the upper limb may be damaged
Mild brachial ischaemia may be amenable to physiotherapy. Acute by a traumatic or crush injury. The embolic source is most frequently
brachial ischaemia may require urgent surgical decompression and the heart (atrial fibrillation or from a mural thrombus post myocar-
immediate revascularization. This may be achieved by thrombolysis dial infarction). Rarely there may be a paradoxical venous embolus
or thrombectomy. Subclavian arterial reconstruction may be if there is a patent foramen ovale or a septal defect. Emboli can arise
required for occlusive or aneurysmal lesions. in the aortic arch after a thoracic dissection. Emboli may arise from
a subclavian artery aneurysm (Fig. 3) as a result of a cervical rib or
arterial TOS. Iatrogenic damage to the subclavian artery during
Venous
attempted subclavian venous cannulation causing upper limb emboli
Venous TOS is managed with thrombolysis in the first instance, fol-
has also been described (see Table 1).
lowed by anticoagulation with heparin until surgical decompression
The patient will complain of an acutely painful arm, which may
by resection of the first rib can be undertaken. Balloon venoplasty is
be weak and paraesthetic. Peripheral pulses are absent.
performed 2–3 weeks after operation to maintain vein patency.

Anaesthetic considerations Treatment and anaesthetic considerations


A majority of patients are young with minimal co-morbidity. A valid Emergency brachial embolectomy to restore blood flow is usually
group and save should be performed. performed under local anaesthesia. Monitored anaesthesia care is
The patient is placed supine with a roll between the scapulae for recommended; patients frequently have significant co-morbidity and
the supraclavicular approach. For the transaxillary approach, the may be restless and in pain.
patient is in a lateral position with their arm abducted to optimize Rarely general anaesthesia may be required particularly if the
surgical access. Large bore venous access is required because of the upper limb has been ischaemic for some time and the patient is un-
risk of haemorrhage. Air embolus can also occur. A high-dose cooperative. Occasionally, a compartment syndrome may occur in
opioid, low-dose hypnotic balanced anaesthetic technique should be the forearm muscles; fasciotomies may be needed.
used. Neuromuscular blocking drugs should be avoided in complex
cases of neurogenic TOS as a nerve stimulator may be used. The
apical pleura can be breached with first rib resection. Invasive moni-
toring is seldom required.
A superficial cervical plexus block can provide cutaneous anal-
gesia when the supraclavicular approach is used; otherwise, local an-
aesthetic infiltration of the wound should be used. Surgery is painful
and patients should be prescribed regular simple analgesics com-
bined with patient-controlled analgesia.
Following first rib resection an erect chest X-ray should be per-
formed in recovery to exclude a significant pneumothorax or hae-
mothorax. Patients should be monitored for any signs of blood loss,
Fig 3 Left subclavian artery arteriography demonstrating a subclavian artery
including losses into drains. Owing to the breach in the apical aneurysm (arrow) in a patient with a cervical rib. The patient presented with
pleura, blood can accumulate in the thoracic cavity rather than in the acute brachial ischaemia secondary to a brachial artery embolus.

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Vascular access for renal dialysis Graft infection may require complete excision to eradicate the infec-
tion whereas native fistula infection can be treated with antibiotics.
In 2011, there were 22 000 patients in the UK receiving renal re- True aneurysms and pseudoaneurysms occur in 3–5% of fistulas
placement therapy via haemodialysis (HD).4 This, coupled with and grafts. Rotating cannulation sites can reduce this risk. Steal com-
high intervention rates to maintain the function of grafts and replace- plicates 5% of grafts and fistulas; the resultant hand ischaemia
ment of failed grafts, means that procedures to establish vascular may require revascularization or graft ligation.
access are amongst the commonest performed by vascular surgeons.
The goal of vascular access is to provide repeated access to the circu-
lation with minimal complications and achieve minimal flow rates Anaesthetic considerations
through the conduit of 600 ml min21 to allow HD.5 Native fistulas can usually be constructed under local anaesthetic;
grafts may require regional nerve block or general anaesthesia.
Owing to the multiple co-morbidities associated with end-stage
Types of vascular access
renal disease, general anaesthesia is frequently avoided. Local an-
There are three main types of access: indwelling catheters, arterio- aesthetic infiltration does not provide motor block and can be inad-
venous fistulae, and arteriovenous grafts. equate when a large amount of vein needs to be transposed.
Regional anaesthetic techniques improve the success rate of vascular
access procedures by producing significant vasodilatation, greater
Indwelling catheters fistula blood flow, and decreased maturation time.8
Indwelling catheters are placed in a central vein, and can be tun-
The choice of regional anaesthetic technique is governed by the
nelled to reduce complications. They have the advantage of requir-
site of the proposed vascular access. Supraclavicular, infraclavicular,
ing no maturation time and are often used where HD is required
and axillary brachial plexus blocks are all suitable techniques.
urgently. High rates of infection and thrombosis are seen with long-
Supraclavicular block provides excellent conditions for upper limb
term use.
vascular access surgery but does not anaesthetize the intercostobra-
chial nerve. The infraclavicular block is a useful alternative to the
Arteriovenous fistulae supraclavicular block particularly if the patient has an indwelling
Arteriovenous fistulae are the first choice6 and are typically con- dialysis catheter in the supraclavicular region. It is recommended
structed with an end-to-side vein –artery anastomosis. This is most when ultrasound is not available as the risk of pneumothorax is ap-
commonly radial artery to cephalic vein, or brachial artery to cephal- preciably lower than with the supraclavicular approach. Axillary
ic vein. Native fistulas have a high rate of primary failure, but their block provides excellent conditions for vascular access surgical
long-term patency is superior to grafts if they mature. They have a procedures distal to the elbow. The musculocutaneous nerve
lower complication rate. Risk factors for primary failure include age, (C6,C7) must be blocked by a separate injection. Ultrasound guid-
obesity, diabetes, peripheral vascular disease, and cardiovascular ance improves the speed and quality of block and reduces inci-
disease. dence of side-effects and complications.

Arteriovenous grafts Conclusions


Synthetic grafts are constructed by anastomosing a synthetic conduit, Anaesthesia for vascular surgery to the upper limb, while less com-
usually expanded polytetrafluoroethylene (ePTFE), between an artery monly performed than in the lower limb, presents its own set of chal-
and vein. The conduit can be straight or looped and range from 4 to lenges. The aetiology of vascular disease means that patients often
8 mm in diameter. Common locations are straight forearm (radial have multiple co-morbidities. Patients require careful pre-assessment
artery to cephalic vein), looped forearm (brachial artery to cephalic and meticulous perioperative care to ensure a successful outcome.
vein), or straight upper arm (brachial artery to axillary vein). Grafts
can be cannulated for HD earlier than fistulas, usually within weeks
where fistulas can take up to 6 months to mature.
Declaration of interest
None declared.

Complications
References
Common complications include thrombosis, infection, steal, aneur-
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Grafts are 3.8 times more likely to require a thrombectomy.7 The 3. Takach TJ, Reul GJ, Cooley DA et al. Myocardial thievery: the coronary –
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