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Highlights • Type A aortic dissection may result in upper limb ischaemia due to progression of dissecting flap. • Despite adequate repair, residual dissecting flap may still propagate in the upper limb vasculature. • Open or endovascular techniques is the treatment of choice for salvageable cases. • Amputation is the inevitable end-point for advanced cases., Introduction Acute type A aortic dissection (AAAD) is a surgical emergency with high operative mortality. Distal propogration of the dissecting flap can lead to malperfusion of territory supplied by the aorta including axillary and brachial arteries causing ischaemia of the upper limb. Case presentation We present a case of a 67 year old gentleman who had AAAD and developed upper limb malperfusion after repair. Despite adequate repair, the residual dissecting flap propagated distally in the upper arm vasculature causing thombosis of the brachial artery. The patient subsequently underwent brachial artery cut-down and embolectomy but revascularization was not achieved. He ultimately required an above-elbow amputation. Conclusion Upper limb ischaemia from AAAD is a rare phenomenon that is mainly due to malperfusion. Majority of malperfusion resolve after aortic dissection repair. This is an unusual case of persistent upper limb ischaemia despite adequate repair due to the direct extension of the residual dissection flap from the aortic root into the brachial artery.

Introduction We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular, and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity. Description A male baby at (36 + 6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post-delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft. Discussion Neonatal limb ischaemia is a rare disease entity with devastating morbidity- including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

A 56-year-old man, an ex-smoker with thrombocytosis (undergoing treatment with aspirin) and hypertension, presented to the emergency department 18 hours after the sudden onset of left-hand cyanosis. He reported of an abnormal sensation and mild motor disturbance. His fifth finger showed severe

Summary Objective The aims of this study were to report on our experience with upper limb ischaemia (ULI), to define the pattern and distribution of disease, describe key demographic features and report on conventional clinical outcomes. Methods This was a single–centre, retrospective, descriptive study. All patients (n = 64) who underwent a surgical intervention for ULI over a 12–year study period were included. Findings were analysed and compared with the current literature. Results A male:female ratio of 0.60 was reported. Two major subgroups of patients were identified. The patients in the thrombo–embolic subgroup (n = 30) were notably younger than expected (mean age 55 years) compared to those in the atherosclerotic occlusive disease subgroup (n = 12, mean age 57 years). Presentation overall was generally late, with 8.6% of acute ULI and 48.3% of chronic ULI patients presenting with irreversible ischaemia and tissue loss, respectively. Thrombo–embolism was the dominant vascular pathology reported in this case series (47%). Ninety–five procedures were performed in 64 patients (89 open, six endovascular). Peri–operative (30–day) mortality rate was 7.8%. Systemic and procedure–related complications were observed in 13 and 23%, respectively. The overall major amputation rate was 10.9%. Adherence to follow up was poor (51% at six months). Conclusion Although few firm conclusions could be drawn, this review has expanded our overall perspective of ULI, specific to the population we serve. Collaboration between African vascular units should be encouraged in an attempt to further define the pattern of ULI by identifying distinct geographical confounders.

Vascular surgery on the upper limb is much less common than on the lower extremity. Upper limb ischaemia is much less common than lower limb ischaemia; in part this is because of the presence of a good collateral circulation around the shoulder. Acute upper limb ischaemia is a real emergency as the ischaemic tolerance of upper limb is much less than the lower limb. In this article we will discuss the management of acute and chronic upper limb ischaemia, thoracic outlet syndrome (TOS), and vascular access surgery for renal dialysis.

The subacute or chronic upper limb ischaemia is mostly non-atheromatous, especially in the young and is of multiple aetiology. Subclavian artery is affected the most and is treated by angioplasty. Brachial artery is least affected, therefore the least is the experience to treat it. At present, intervention of upper limb vessels distal to axillary artery is taken as duplication of intervention technique used for coronary or lower Limb. This case report describes a 28-year-young man who underwent successful angioplasty and stenting of a subacute totally occluded brachial artery of 2 weeks duration possibly of post-traumatic aetiology. Kissing guide wire technique via transradial approach was used in this case, the first experience in upper limb ischaemia management distal to axillary artery.

An 83-year old man who had used bilateral axillary crutches for 67 years was referred to our hospital for acute left upper limb ischaemia. He underwent successful recanalization through emergent catheter thromboembolectomy. However, a crutch-induced left brachial artery aneurysm was subsequently detected by computed tomography. Therefore, we performed aneurysm exclusion and subsequent saphenous vein bypass grafting. When a crutch user presents with upper limb ischaemia, a high index of suspicion and early identification of the crutch induced vascular injury are mandatory for appropriate treatment.

Irradiation arteriopathy, although rare, is a recognised entity following radiotherapy for the management of advanced cancers. It is known to manifest in varied forms and can be chronic and progressive. We present a case of an acute upper limb ischaemia following deep inferior epigastric artery perforator (DIEP) free flap reconstruction for a chest wall defect in a patient who had previously undergone radiotherapy 25 years back for carcinoma of the breast. It is envisaged that the axillary artery was thrombosed secondary to radiation arteriopathy and the collaterals that had developed were probably damaged during debridement of the irradiated unhealthy tissue prior to free flap reconstruction. A cross-limb vascular graft tunnelled under the flap restored the perfusion to the limb. We propose that the possibility of radiation arteriopathy should be considered and a preoperative arteriogram should be performed prior to planning any major surgical reconstruction in patients having undergone irradiation to major vascular beds.

The case is reported of a 32 year old woman with acute on chronic upper limb ischaemia due to thrombus from a cervical rib that had compressed the right subclavian artery of her dominant hand after use of a rowing machine. If not detected early, this condition can be debilitating especially in the young. A multidisciplinary approach is advisable to ensure a satisfactory outcome.

Introduction Clinical manifestations of hypertrophic bifurcated distal biceps tendons are rarely described. We report the first known case of brachial arterial entrapment resulting from this unusual anatomical variable. Report A 24-year-old gentleman presented with positional upper limb ischaemic symptoms. Initial investigation was unremarkable. Operative exposure of the ante-cubital fossa revealed compression of the brachial artery by a hypertrophic bifurcated distal biceps tendon. Partial division of the tendon led to resolution of symptoms. Discussion In challenging cases of upper limb ischaemia surgical, intervention may be justified for both diagnostic and therapeutic purposes.

Objectives to investigate the outcome of patients undergoing axillo-axillary bypass grafting for symptomatic subclavian artery stenoses or occlusions. Design retrospective case-note review and prospective review of patients available for follow-up. Patients and methods sixteen patients had axillo-axillary grafts in a 17-year period. Ten patients were available for review and assessed clinically, by measurement of arm blood pressures, and by duplex scanning of their grafts. Results one patient died and three grafts occluded within 30 days of operation. Nine out of 10 grafts scanned were patent, with three further grafts clinically patent at death. Overall secondary patency was 75% at a combined median follow-up of 56 months (range 12–204 months). Recurrent symptoms occurred in two patients, one with an occluded graft and one with a patent graft. Conclusion axillo-axillary bypass grafts give good long-term symptom-free results.

We present the case of an acute or chronic ischaemia of the upper limb due to extrinsic compression and thrombotic occlusion of the left subclavian artery successfully bypassed with a subclavian to axillary artery venous auto-graft.

Introduction Thorascopic sympathectomy is a widely used procedure for the treatment of intractable palmar hyperhidrosis. Report A 24-year-old woman who underwent thorascopic sympathectomy for hyperhidrosis in 2005 presented on more than 30 occasions with recurrent right distal upper limb ischaemia secondary to repetitive episodes of vasospasm. The patient did not have preoperative symptoms consistent with Raynaud’s syndrome. We observed a reduction in the symptomatic relief offered by Iloprost treatment over a period of five years. Discussion This is the first report of distal upper limb ischaemia following thorascopic sympathectomy. We highlight the development of resistance to repeated Iloprost infusions that we observed in this case.

SummaryA case of unilateral upper limb ischaemia from ergot overdosage is presented. An unusual feature was a median nerve neuropathy suggestive of carpal tunnel syndrome. The arteriographic appearances are demonstrated and management discussed.

General supportive measures, the ability to avoid infection, the natural tendency to improvement and the feasability of major reconstructive procedures later suggest that neonatal limb ischaemia should be managed conservatively at first, despite an alarming appearance. The number of infants at risk, especially due to prematurity and effective resuscitation, is theoretically increasing.