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Emboli to Upper Extremity Vessels

- Clinical Presentation:
    - sudden onset of pain, pallor, paresthesias, variable paralysis, and absence of distal pulses;
    - only 15% of all arterial emboli lodge in the upper extremity;
    - sudden atraumatic onset in conjunction with atrial fib or recent MI strongly implicates an embolic event;
    - origin: 70% of emboli are of cardiac origin;
         - mural thrombus associated with MI
         - thrombus lodged within a ventricular aneuysm
         - dyskinetic atrium of atrium fibrillation;
         - cardiac emboli are usually large & cause sudden acute obstruction at fairly proximal level, often bifurcation of the brachial art
         - most of remainder arise from subclavian artery at the thoracic outlet due to compression from;
              - fascial bands in the scalene musculature
              - cervical ribs
              - anomalous first ribs;
              * emboli of arterial origin are smaller & travel more distally in vascular tree;

- Treatment
    - large proximal emboli
         - initiate heparin as soom as recognized
         - many large emboli are amenable to embolectomy
         - local anesthesia to expedite treatment
         - fogarty catheters, can be used as far distally as the wrist;
         - observe closely for compartment syndrome following revascularization;
         - coumadin for at least 3 months;
    - emboli distal to the wrist;
         - initially treat to reverse vasospastic component of ischemia
               - axillary block
               - digital or wrist block with marcaine
               - stellate ganglion block;
         - if no response within several hours proceed to heparin
         - if still no response and tissue loss is expected
               - discontinue heparin
               - consider thrombolysis with intra-arterial or IV urokinase

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