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Application of Perforator Flap Arterial Anatomy in the Design of Interposition Arterial Bypass Grafts in Hypothenar Hammer Syndrome
Avinash Islur, MD, FRCSC
University of Manitoba, Winnipeg, MB, Canada

Purpose: Hypothenar hammer syndrome is an uncommon vascular condition in which the ulnar artery undergoes repetitive trauma leading to eventual aneurysm and/or thrombosis. Interpositional vein grafts across the occluded segment have been the mainstay of treatment. Cardiac surgery literature demonstrates improved long-term patency rates in radial artery grafts compared to vein grafts. It could be extrapolated that arterial bypass grafts may provide a better alternative to vein grafts in hypothenar hammer syndrome. Arterial grafts have typically been taken from the radial artery; however, knowledge of perforator free flap anatomy has enabled the possibility to design various configurations for arterial grafts from other donor sites. The characteristics of these donor arterial vessels may provide additional advantages over vein grafts. Thus the purpose of this study is to determine whether arterial interposition bypass grafts harvested from commonly used perforator free flap sites, DIEP and ALT, offer an advantage over vein grafts in the treatment of hypothenar hammer syndrome.
Method: A retrospective review of all patients undergoing ulnar artery bypass grafting for hypothenar hammer syndrome since July 2008 was performed.
Results: Five patients presented with hypothenar hammer syndrome. All patients underwent ulnar artery bypass grafting with the use of an arterial bypass graft. A deep inferior epigastric artery was used in four patients and the descending branch of the circumflex femoral artery was used in one patient. All grafts were performed proximally to the distal ulnar artery and distally to common digital arteries. Minimum of two distal arterial anastomoses were performed. Two patients underwent additional anastomosis to the superficial palmar arch in addition to the common digital arteries. All arterial bypass grafts have remained patent to date with a mean follow-up of 14 months as demonstrated on Allenís testing and angiogram. All patients have had resolution of symptoms. All donor sites healed uneventfully with no symptoms of muscle weakness. One patient complains of persistent parasthesia around the donor site scar.
Conclusion: Arterial bypass grafts harvested from donor sites commonly used for free flaps provides an alternative to vein grafts with numerous advantages: better tissue handling, better size match at proximal and distal anastomosis sites, and increased branching patterns to allow for numerous end-to-end distal anastomoses. Improved long-term patency rates and decreased stenosis rates maybe due to the lack of intimal hyperplasia.

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