Findings: Images from left upper extremity arteriogram demonstrate extensive filling defect within the radial, ulnar and interosseous arteries (Image 1) and extremely limited filling of the palmar arch and digital vessels (Image 2).
Diagnosis: Acute left upper extremity arterial thrombosis.
Discussion: This patient presented with clear cut clinical and angiographic evidence of acute upper extremity arterial thrombosis. Although a less common occurrence than lower extremity arterial thrombosis, upper extremity thrombosis presents some unique clinical and technical challenges. Potential etiologies include an underlying atherosclerotic lesion precipitating thrombosis, embolization of thrombotic material from the heart or proximal upper extremity arterial vasculature, Buerger disease (thromboangitis obliterans) or an underlying hypercoagulable state. In this patient, arteriography revealed no evidence of a proximal lesion (Images 3 and 4). Cardiac ultrasound was unrevealing. The vasculature appeared normal following therapy, excluding Buerger disease and the patient's hypercoagulable work-up is pending.
Therapeutic options prior to the era of thrombolytic therapy included surgical thromboembolectomy and/or limited bypass procedures when appropriate. However, these options were often either not feasible or had limited success and amputation was often necessary. Catheter directed intra-arterial thrombolytic therapy offers a relatively noninvasive therapeutic option with a fairly high success rate. The shorter the duration of thrombosis, the more likely the therapy is to be successful. Lengthy infusions over two to three days are often necessary to achieve success. In this patient, intra-arterial Urokinase therapy over a three-day period resulted in complete thrombolysis with no clinical residua (Images 5 and 6).
References:
Valji K, Bookstein JJ. Thrombolysis: Clinical Applications. In: Abram's Angiography,
Little Brown Publishers; 1997:132-159.
Loring LA, Hallisey MJ. Arteriography and Interventional Therapy for Diseases of the Hand.
Radiographs, 1995;15:1299.
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