What is the treatment for an arterial clot on the axillary artery?

Treatment of Arterial Clot on the Axillary Artery

Immediate anticoagulation with unfractionated heparin (5000 IU bolus or 70-100 IU/kg, followed by continuous infusion) or low molecular weight heparin (enoxaparin 1 mg/kg twice daily) must be initiated upon clinical diagnosis, followed by urgent revascularization for salvageable limbs. 1

Immediate Medical Management

Upon clinical diagnosis of acute axillary artery thrombosis, initiate the following immediately:

• Analgesia for pain control 1
• Intravenous fluids to maintain perfusion 1
• Anticoagulation (unless contraindicated) to prevent further embolization and thrombus propagation 1
  • IV unfractionated heparin: 5000 IU bolus or 70-100 IU/kg, then continuous infusion adjusted by aPTT or ACT 1
  • Alternative: Subcutaneous LMWH (enoxaparin 1 mg/kg twice daily) 1
• Address metabolic derangements: Correct acidosis and hyperkalaemia as needed 1

Assessment of Limb Viability

The urgency of revascularization depends on neurological function and sensory status 1:

Salvageable limb (urgent revascularization):

• No sensory loss with normal motor function, OR
• Sensory loss limited to toes with no muscle weakness, OR
• Sensory loss in toes with rest pain and mild-to-moderate muscle weakness 1

Immediately threatened limb (emergency revascularization):

• More extensive sensory and motor deficits requiring immediate intervention 1

Non-salvageable limb:

• Complete sensory loss with loss of motor function
• Absence of both arterial and venous Doppler signals with extensive motor deficit
• Consider primary amputation or palliative care 1

Diagnostic Imaging

Obtain imaging to guide therapy, but do not delay treatment if limb is immediately threatened 1:

• CTA is preferred for rapid assessment of clot location and underlying arterial disease 1
• Duplex ultrasound can determine treatment urgency when neurological assessment is challenging; loss of arterial signal indicates limb threat 1
• DSA or MRA are alternatives based on local availability and expertise 1
• Consider biomarkers: Elevated creatinine kinase or myoglobin indicate rhabdomyolysis and predict amputation risk, kidney failure, and mortality 1

Revascularization Strategy

For Native Vessel Thrombosis (In Situ Clot):

Endovascular approach is preferred for viable limbs 1:

• Catheter-directed thrombolysis if guidewire can cross the lesion 1
  • Agents: Alteplase, reteplase, or urokinase 1
  • Consider adding glycoprotein IIb/IIIa antagonist (abciximab) to reduce distal emboli 1
• Regional thrombolysis if guidewire cannot cross 1
• Mechanical thrombectomy options: Ultrasound-assisted thrombolysis, suction embolectomy, or rheolytic therapy—particularly useful when thrombolysis is contraindicated 1

Advantages of endovascular approach: Similar 1-year limb salvage rates to surgery with lower mortality, allows treatment of underlying lesions, and gradual reperfusion may avoid reperfusion injury 1

Reserve surgical thrombectomy/bypass for:

• Failed endovascular therapy 1
• Unacceptable delay that jeopardizes limb viability 1
• Non-viable limbs requiring immediate intervention 1

For Embolic Occlusions:

Isolated suprainguinal emboli should be removed surgically 1:

• Surgical embolectomy is the consensus recommendation for isolated proximal emboli 1
• If embolic fragmentation with distal embolization has occurred, catheter-directed thrombolysis becomes the preferred option 1
• Echocardiography is not necessary before thrombolytic therapy 1

Post-Revascularization Management

After successful thrombus removal 1:

• Treat underlying arterial lesions with endovascular therapy or open surgery to prevent recurrence 1
• Perform surgery in hybrid room when possible to allow completion angiography and initiate local lysis if residual clot is visualized 1
• Investigate etiology: Holter-ECG, echocardiogram, and aortic imaging to identify thromboembolic sources requiring anticoagulation 1
• Evaluate for hypercoagulability: PT, aPTT, platelet count, factor V Leiden, prothrombin C-20210a, anti-cardiolipin antibody, protein C, protein S, and anti-thrombin III—particularly in atypical presentations 1
• Consider prothrombotic syndromes: Antiphospholipid syndrome and vasculitis if clinically suspected 1
• Initiate statin therapy: Improves outcomes after revascularization 1

Critical Pitfalls to Avoid

• Do not delay anticoagulation while awaiting imaging or hypercoagulability workup; initiate immediately upon clinical diagnosis 1
• Systemic thrombolysis has no role in acute limb ischemia treatment 1
• Do not universally favor endovascular over surgical approaches; the severity of ischemia, ability to tolerate surgery, and distinguishing embolic from in situ lesions guide therapy selection 1
• Recognize that long-term outcomes after catheter-directed thrombolysis show relatively poor patency and substantial amputation risk despite high initial angiographic success 1