Upper limb artery surgery

Arterial conditions of the upper limbs are far less frequent than those of the lower limbs, but when they produce symptoms of acute or chronic ischaemia they can require surgical or endovascular revascularisation techniques. The interventions performed at the level of the arm include arterial bypass, arteriovenous fistulas for dialysis access and surgery for scalene (thoracic outlet) syndrome.

Upper limb artery surgery at a glance

• Indications: acute or chronic ischaemia of the arm, vascular access for dialysis, vascular and nerve compression at the base of the neck
• Frequent causes: acute embolism and trauma (more frequent than chronic disease at this level), atherosclerosis, post-traumatic stenosis or aneurysm
• Interventions: arterial bypass, arteriovenous fistula, scalene syndrome surgery
• Prior diagnosis: thorough clinical examination, arterial Doppler ultrasound, arteriography or CT/MR angiography

When is arm artery surgery necessary?

Acute arterial disease — especially acute embolism and trauma — is more frequent in the upper limbs than chronic disorders of the arterial system. The most frequent causes of chronic ischaemia of the upper extremities are atherosclerotic disease and late stenosis or aneurysm related to a previous traumatic injury. Other less frequent causes — such as arterial thoracic outlet syndrome (with or without a post-stenotic aneurysm) and upper extremity aneurysm — can also call for revascularisation.

The intervention becomes necessary when the symptoms (pain, cramps, weakness, coldness of the arm) become severe or disabling, or when the viability of the limb is threatened. Details about symptoms, causes and diagnosis are on the Arterial conditions page.

Upper limb arterial bypass

Arterial bypass is the operation most frequently performed in vascular surgery. It involves surgically creating a new arterial route that bypasses the area where the artery is blocked or narrowed.

Why is it needed?

The consequence of the narrowing is that the anatomical segment downstream of the arterial lesion no longer receives enough blood and oxygen. Ineffective perfusion causes major problems in the tissues of the upper limb. Altered, hardened artery segments cannot be treated with medication — a new vascular route has to be created.

How does the intervention work?

Preparation is done through a thorough clinical examination and an arterial Doppler ultrasound; the main investigation is arteriography or its modern variants — CT and MR angiography. The operation is performed using a synthetic graft or a portion of vein harvested from the patient. Technically, the graft is connected by suture to the artery above and below the lesion, under locoregional anaesthesia.

Most frequently, bypass is performed on the lower limbs, but it can also be done on the upper limbs when needed. The intervention serves both to save the limb and to relieve the symptoms.

Arteriovenous fistula for dialysis access

The arteriovenous (AV) fistula is how patients with kidney failure are connected to the dialysis machine. Treatment starts with the insertion of two needles into the fistula: one needle takes the blood out and sends it to the machine, where it is filtered, and the second allows the blood to be returned safely to the body.

Why an AV fistula?

The arteriovenous fistula is considered the gold standard for vascular access in haemodialysis patients and the first choice whenever possible: AV fistulas are associated with reduced mortality and morbidity among haemodialysis patients, compared with other types of vascular access, which carry a relatively high risk of infection and clotting.

How is it created?

An AV fistula is a connection created surgically between an artery and a vein. A surgical procedure, performed in the operating theatre, is needed to join the two vessels. Once created, the fistula needs a maturation period before it can be used for dialysis — the exact interval is established by the doctor.

Surgery for scalene (thoracic outlet) syndrome

Scalene syndrome covers all the phenomena of vascular and nerve compression at the level of the thoracic outlet — the upper opening of the rib cage, at the base of the neck. The syndrome appears through the pinching of the subclavian vascular bundle, caused by congenital or acquired abnormalities: spasm, myositis, muscular hypertrophy and others.

When is surgery necessary?

Surgery is indicated in the case of compression of the subclavian artery, once the spasm has set in and the blood flow of the upper extremity has diminished. Lesions of the arterial wall can also appear, and over time thrombosis and embolism can develop — situations that call for surgical treatment.

What techniques are used?

• Microsurgery through a supraclavicular approach — approaching the area above the collarbone, followed by neurolysis of the brachial plexus, removal of the scalene muscle (scalenectomy) and the release of the underlying (subclavian) blood vessels. This approach avoids resection and has proved to be an effective treatment.
• First rib resection — when the first rib (or a fibrous band extending from it) compresses a vein, an artery or the nerve bundle, part of the first rib and the compressive fibrous tissue can be removed through a first rib and thoracic resection. The scalene muscles can also be removed.
• Removal of a cervical rib — in some cases there is a rudimentary or cervical rib causing the compression; it can be removed using the same technique.

The result of the intervention is increased blood flow and reduced nerve compression.

Frequently asked questions

What symptoms do arm arterial conditions cause?

Discomfort or pain in the arms, a feeling of tightness, heaviness, cramps or weakness in one or both arms, coldness of the hand. In advanced cases, exertional pain, ischaemic pain or ulceration appear.

Is surgery always necessary?

No. In most asymptomatic patients, medical treatment is the first option. Revascularisation is proposed for severe or disabling symptoms, bilateral stenosis, stenosis with an ipsilateral arteriovenous fistula for dialysis, or in special situations related to coronary surgery.

Open or endovascular surgery?

When revascularisation is proposed, both endovascular and open surgical options can be useful — the choice depends on the characteristics of the lesion and on the patient’s risk.

How long does an AV fistula take to mature?

The fistula needs a maturation period after it is created, before its first use for dialysis. The exact interval and the necessary check-ups are established by the treating doctor, depending on how the vessel develops.