Surgical Treatment of Chronic Upper Extremity Ischemia
Mary C Ghere, MD; Benjamin C McIntyre, MD; Michelle Buckius, MD; Mitchell Marc, MD; John G. Winscott, MD
University of Mississippi, Jackson, LA
Introduction: Ischemia of the hand is a very serious condition. Like ischemia in the lower limbs, it can be extremely debilitating. Acutely it can lead to digital amputation, and in severe cases necessitate amputation of the hand. Surgical intervention for chronic upper extremity ischemia is not performed as often as revascularization procedures for the lower extremities. Surgical intervention however, still plays a valuable role in the treatment of these difficult patients. In particular surgical revascularization procedures may significantly improve the quality of life for this patient population who suffers from unrelenting pain and threatened limb loss.
Methods and Case Description: A literature review was performed using key words: Hand Ischemia, Radial Artery Occlusion, Ulnar Artery Occlusion, Radial Artery Bypass, and Palmar Arch Bypass.
We demonstrate the role of surgical intervention in a 58-year-old woman that presented with acute on chronic ischemia of the dominant hand. She had rest pain, gangrene of the index fingertip, and ischemic ulceration of the adjacent long finger. She underwent angiography that demonstrated occlusion of both the radial and ulnar arteries over several segments and specifically segmental occlusion of the radial artery as it transitioned to the deep palmar arch. Interventional attempts at revascularization were unsuccessful. She underwent segmental bypass with reversed cephalic vein.
Results: She had successful resolution of her rest pain and healing of her ischemic ulcerations. There was no further necrosis of the index finger, and she went on to have an amputation of the distal phalanx, which healed without consequence.
Conclusion: Our case highlights the potential for vascular bypass to targets as distal as the digital arteries and the palmar arch. These patients benefit from a multidisciplinary team: including interventional radiologists, vascular surgeons, and experienced microsurgeons to successfully revascularize a vascular occlusion deep within the palm. Despite the surgical challenges of operating in this patient population, it is important to note that there are treatments that can avoid amputation, heal ulcerations, control rest pain and provide the patient with a return of function to the hand.
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