Limb amputation remains one of the more feared results of disease and interventional therapy . Over the years and centuries, a number of ritualistic, punitive, legal, and iatrogenic causes of limb loss have been delineated by Kirkup [1] (Table 22.1). A history of human mutilation and amputation has been documented in prehistoric caves from France and Spain with partial amputation of fingers and thumbs dating back 25,000 years. This procedure has even been performed more recently in the 1960s in the New Guinea Dugum Dani tribe. Such was also the case in the Moendan tribe in India. In the Assiniboine and Crow Indians of North America, using a sharp knife or a tomahawk, amputation was done in mourning. More recently in 2005, a South Korean physician was arrested for assisting in a self-inflicted finger amputation [1].

Punitive thumb and great toe amputations were performed on prisoners according to the Book of Judges. And, in 1314, three English soldiers under the king’s service had punitive hand amputations after the Battle of Bannockburn. In Peru, during the sixteenth century, infringement on tribal laws was punished by amputation of the hand for theft or a foot for laziness or both arms for rebellion. In 2000 bc, in Babylon, a physician could lose both hands if an operation on an eye failed.

Iatrogenic causes for amputation of an extremity have been known for centuries. Tourniquets have long been known to cause ischemia of the extremity upon which they were applied. Misapplied fracture splints and bandages and the consequent result were known by Hippocrates. In 1798, Folly—a Danish surgeon—reported on the death of 19 of 20 individuals from gangrene as a result of inappropriately placed splints and bandages for fractures. Unfortunately, these gangrenous results have more recently been noted in Ethiopia and with misapplied tourniquets placed on the battlefield during World War I. The problem was reportedly reduced after instructional programs.

Other iatrogenic or self-inflicted causes of extremity loss followed such items as seton treatment of wound infection or accidental scratching or cutting oneself in an operating room, prior to sterile techniques, knowledge, and antibiotics. Lack of understanding and thus appropriate advice by uninformed physicians has been known to lead to ischemia or loss of an extremity. We have been requested to assist in the treatment of such patient complications to avoid progressive ischemia or amputations, including accidental self-induced amputation of the upper extremity.

Over the past few decades, vascular surgery and vascular interventional procedures have escalated in both numbers and complexity. We have seen a large number of individuals with vascular complaints both electively and urgently, as well as in emergency situations [2]. These problems have included the outpatient as well as the inpatient situation. When evaluating patients, a complete history and physical exam are required in order to provide the most appropriate recommendation and therapy program for the individual. Initially, in the elective situation, when possible, noninvasive or minimally invasive procedures and testing are first utilized. Moreover, in the urgent or more emergent situation, such as a ruptured aneurysm, direct invasive and therapeutic procedures are usually required—time permitting. In these life or limb situations, the frequency and risk for complications are much greater. Immediate ambulance or ER to the OR may be the best approach with no intervening delays.

However, as the physician intervenes with more complicated and innovative procedures, the risk of side effects from the potential beneficial therapy also increases. Life and death situations, as well as limb salvage, must be balanced against the potential for complications. When the patient has severe ischemia or is in a shocklike situation , the treating team utilizes the most appropriate therapy for the situation and the patient—even though in many instances the treatment is risky and highly complicated. Such intervention may lead to successful results for the patient, no improvement, continued deterioration, or to adverse side effects and complications—including loss of an extremity or life.

Over the years, we have seen a number of patients with multiple medical disorders who required intervention to save a life or an extremity. Many of these patients have had successful therapeutic approaches including vascular intervention utilizing either the open surgical approach or the percutaneous catheter system. Unfortunately, a number of these individuals required extensive intervention and/or multiple interventional procedures. Thus, the chance for vascular compromise and major vascular complications has developed during the course of treatment in a few patients. The causes of significant extremity ischemia or premorbid situations may present a difficult treatment challenge—especially when one is simultaneously working to salvage a life.

Listed above are a number of etiologies for iatrogenic ischemia of the extremities (Table 22.2). The most common causes of ischemic compromise of an extremity occur after other treatment modalities result in either embolic (single or shower emboli) or vascular thrombotic occlusion during treatment, guidewire perforation of the vessel or plaque, plaque disruption and embolization, and inadvertent transection of vessels or clot disruption at the time of treatment of aneurysms . Most of the time, the source of significant embolic clot originates in the larger vessels during clamping or circumferential dissection about the clot-containing aorta. Other ischemic causes include inadvertent intra-arterial epinephrine, arterial pressure lines, large-bore catheters in small or tiny pediatric vessels, and prolonged clamp or tourniquet time. Almost any artery may inadvertently be involved in an iatrogenic injury or vascular occlusion. The more common vessels which might be occluded and lead to significant extremity complications or loss are delineated in Table 22.3.

Fortunately, most patients have adequate circulation and a competent collateral circulatory system. This is well demonstrated by the large number of patients, in whom the radial artery is utilized for arteriovenous dialysis fistula creation, cardiac catheterization studies, and placement of arterial pressure monitoring lines [3]. Most of these patients tolerate the procedure well and require no further treatment at the completion of the radial or brachial artery procedure . Unfortunately, the occasional procedure will not proceed as planned. We have seen several patients with hand or arm ischemia , including one with blackened gangrene of the arm to above the elbow, following arterial monitoring line placement (Fig. 22.1). We have also seen patients lose digits after AV fistula creation for dialysis. Volkmann’s contracture and persistent limb ischemia have resulted in upper extremity amputation after a brachial artery catheterization for hemodynamic monitoring [4]. Radial artery harvest for coronary surgery or catheterization for monitoring has also led to ischemia or amputation [5, 6]. Thus, radial artery pressure monitors as well as arteriovenous shunt creation for hemodialysis require careful consideration of the collateral circulation as well as pressure monitoring policies [7]. Irrigation techniques, anticoagulation, and pressure cuff application programs need constant awareness and compliance. Enclosed is an example of a monitoring program to minimize the risk of radial artery thrombosis, digital or upper extremity ischemia, and gangrene—especially in the low cardiac output patient (Table 22.4).