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Upper Extremity Thrombo-embolectomy Using Preoperative Ultrasound Duplex as the Sole Diagnostic Imaging Method
Anil Hingorani, M.D., enrico ascher, md, natalie marks, md, fred usoh, md, alexsander shiferson, do, robert jimenez, md, ed aboian, mdn, theresa jacob, PhD, thomas mcintyre, PA.
Maimonides Medical Center, Brooklyn, NY, USA.

Rationale and Objective:
Although the current standard of care for patients with upper extremity acute ischemia is pre-operative angiographic-guided thrombo-embolectomy, at our institution, 59 patients underwent thrombo-embolectomies using pre-operative ultrasound findings as the sole diagnostic imaging method.

Method:
Between May 2000 and December 2009, 59 patients [21 males and 38 females, with a mean age of 74 years, and a range of 42 to 94 years, ± 18 (SD)] underwent upper extremity (UE) thrombo-embolectomies based on pre-operative ultrasound findings. The indications were UE acute ischemia resulting from thrombo-emboli to the brachial (38), ulnar (14), radial (12), or axillary (8) arteries in various combinations. 41 out of 59 patients had a completion angiogram done which demonstrated patent vessels. Follow -up consisted of post-operative upper extremity duplex when clinically indicated,
On-going clinical evaluation, and scheduled clinic visits.

Result:
Mean follow-up was 12 months, ± 23 (SD). A 49% (29 patients) overall mortality resulting from co-morbid conditions (MI=17, ESRD=10, sepsis), and a 30day mortality of 22% (13 patients) were observed. Other co-morbid conditions were as follows: atrial fibrillation (26), congestive heart failure (11), hypertension (30), and diabetes mellitus (16). 3 cases required more than thrombo-embolectomies based upon completion angiography. One had required an immediate brachial-to-radial bypass, while the other two patients required axillary-to-brachial bypass - one performed on post-operative day one, with the other at 9 months, respectively.

Conclusion:
Pre-operative ultrasound and completion angiogram is an effective and safe diagnostic method for the management of acute upper extremity ischemia.


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