Microsurgical revascularisation of the hand in scleroderma

Total Percutaneous Revascularization of the Hand to Treat Refractory Digital Ischemia in Advanced Systemic Sclerosis

We present the case of a young woman with systemic sclerosis (SSc) and refractory digital ulceration who was successfully treated with percutaneous revascularization of chronically occluded ulnar and radial arteries. To our knowledge, this is the first detailed report of limb salvage in SSc-induced hand ischemia in which contemporary endovascular techniques were used. (Level of Difficulty: Advanced.).

Upper Extremity Angiographic Patterns in Systemic Sclerosis: Implications for Surgical Treatment

PURPOSE

Conventional angiography is often used in the preoperative work-up of hand surgery patients with systemic sclerosis. The goal of this study was to propose a classification system based on the pattern of arterial involvement in a series of upper extremity angiograms. The authors hypothesized that this classification system would demonstrate high inter- and intrarater reliability.

METHODS

A retrospective review of 110 upper extremity angiograms in patients with systemic sclerosis (obtained between 1996 and 2017) was performed. Images were classified into 4 types based on the patency of the radial and ulnar arteries at the wrist, and into 3 subtypes based on the patency of the superficial and deep palmar arches. Classification reliability was compared with Fleiss' Kappa (for inter-rater) and Cohen's (for intrarater) coefficient between 4 fellowship-trained hand surgeons and a hand fellow.

RESULTS

The inter-rater reliability between all 5 observers using types alone was 0.83 (0.80-0.85), whereas the inter-rater reliability using subtypes was 0.64 (confidence interval [CI] 95%, 0.62-0.65). The intrarater reliability using types alone ranged from 0.80 to 0.95, whereas intrarater reliabilities using subtypes were 0.81 (CI 95%, 0.72-0.90), 0.78 (CI 95%, 0.69-0.87), 0.87 (CI 95%, 0.80-0.95), 0.64 (CI 95%, 0.53-0.75), and 0.92 (CI 95%, 0.86-0.98) for the 4 attendings and a hand fellow, respectively. Fifty-seven percent of angiograms were interpreted as having loss of ulnar artery patency at the wrist (type 2) with 77% having additional loss of superficial palmar arch patency (type 2A).

CONCLUSIONS

This large series of angiograms in patients with systemic sclerosis demonstrates a classification system for conventional angiography that shows high inter-rater and intrarater reliability using type alone. When subtypes were used, the inter-rater and intrarater reliabilities decreased to moderate and moderate-to-high, respectively.

CLINICAL RELEVANCE

This study represents the first step in establishing a classification system that, by grouping patients with similar angiogram findings, may allow for targeted research into risk stratification, monitoring, and treatment in systemic sclerosis.

Calcinosis of the Hand in Scleroderma: A Case Report

Calcinosis associated with scleroderma is a well recognized phenomenon. Fifteen to 44% of patients with systemic scleroderma and associated CREST (calcifications, raynaud's phenomenon, esophageal motility disorder, sclerodactyly and telangiectasias) syndrome have deposition of calcium in the fingers and hands. The tumourous effect may limit motion, cause neuropraxia, compound microangiopathy or present as calcific ulcers. This report describes the case of a patient with scleroderma and CREST syndrome in whom calcinosis in the hand resulted in severe, debilitating pain necessitating surgical evacuation of the deposits. The patient had complete pain relief in the postopertive period. A further surgical extirpation of calcium was required for recurring pain at six months after surgery. The patient has remained symptom free since that time. The rare occurence of excruciating pain prompted this report and literature review.

Surgery of the Hand in Severe Systemic Sclerosis

Ten patients with scleroderma and severe hand problems required surgery, and seven were available for follow-up (two died from scleroderma-related complications and one was lost to follow-up). The mean duration of follow-up was 4 (range 1.5–9) years. Thirty-three procedures were carried out, including five metacarpophalangeal joint exisional arthroplasties, 13 proximal interphalangeal joint fusions, ten distal interphalangeal joint fusions, and one thumb interphalangeal joint fusion. The metacarpophalangeal joint excision arthroplasties and proximal interphalangeal joint fusions were performed for the correction of severe fixed “finger-in-palm” deformities. Lesions of cutaneous calcinosis were removed in four patients.

Fixation was satisfactory in all cases of interphalangeal joint fusion, with no cases of non-union. Wound healing was satisfactory in six of seven patients. A second surgical procedure was required in three patients for the removal of tension band wires following interphalangeal fusion. Calcinosis was effectively removed using a high-speed dental burr. The results of hand surgery for systemic sclerosis are reliable, but goals must be limited and patient expectations should be modest.

Role and rationale for extended periarterial sympathectomy in the management of severe Raynaud syndrome: techniques and results

There is no consensus regarding etiology or best surgical technique for severe Raynaud syndrome in patients with connective tissue disease. Observations after 30 years' experience in more than 100 cases led to the conclusion that an extended periarterial sympathectomy (with or without vein-graft reconstruction) and adjunctive use of Botox topically will offer benefits that exceed palliation and reduce recurrent ulcerations. In this article the rationale for this approach is reviewed, techniques and results are outlined, and a hypothesis for the mechanism of Raynaud attacks is offered.

Reconstruction of the ischemic hand

Ischemia of the hand remains an uncommon condition, but problems with arterial perfusion of the hand can arise from trauma (open and closed), thrombosis, or arteriovascular disease. Certain identifiable patterns are seen with hand ischemia, usually discernable according to which one of the major arteries (radial or ulnar) are involved. This article discusses the origin and management of ischemic hand conditions, with an emphasis on recognizing the patterns of ischemia that are commonly seen.

Treatment of chronic digital ischemia with direct microsurgical revascularization

The authors present their technique for treating digital ischemia using a radial-to-digital artery bypass graft performed in a bloodless field under tourniquet with the use of a microscope. The outcomes in 6 patients were resolution of fingertip ulcers, avoidance of more proximal amputations, and elimination of ischemic pain.

Arteriographic evaluation of vascular changes of the extremities in patients with systemic sclerosis

BACKGROUND

Although digital ulcerations frequently occur in patients with systemic sclerosis (SSc), there have been few reports on the macrovascular involvement.

OBJECTIVES

To evaluate the macrovascular involvement in patients with SSc exhibiting digital ulceration or gangrene.

METHODS

Transfemoral catheter arteriography of the upper and/or lower extremities was performed in eight patients (one man and seven women, age range 42-71 years) with SSc exhibiting digital ulceration or gangrene. The background of the patients, such as autoantibody profiles and vascular risk factors including smoking habits, was also investigated.

RESULTS

Macrovascular involvement was detected in seven of eight patients. In three of seven patients who underwent arteriography of the upper extremity, occlusion was limited to the digital arteries. Obliteration of the ulnar artery and superficial palmar arch was detected in three of seven patients, and the radial artery in one patient. Only one of five patients who underwent arteriography of the lower extremity showed the occlusion limited to digital arteries of the foot. Occlusion of the posterior tibial artery, dorsalis pedis artery and arcuate artery was detected, each in one patient. Two patients showed occlusion of the plantar arch. Overall, the occlusion of arteries proximal to the digits was demonstrated in four of eight patients. Three of the four patients were positive for antitopoisomerase-1 antibody and had diffuse cutaneous SSc (dcSSc) with multiple skin ulcers or gangrene.

CONCLUSIONS

Macrovascular involvement as detected with arteriography is not rare in SSc patients with digital ulceration or gangrene. Moreover, the vascular occlusion proximal to the digits seemed to be frequent in antitopoisomerase-1 antibody-positive dcSSc patients with multiple skin ulcers or gangrene.

Surgery for ischemic pain and Raynaud's' phenomenon in scleroderma: a description of treatment protocol and evaluation of results

Although the literature suggests that palmar sympathectomy (PS) with or without vascular reconstruction may improve ischemic digital pain, fingertip ulceration, and cold intolerance in patients with scleroderma, the question regarding long-term efficacy still remains. This retrospective study of six patients (eight hands) operated on between 1995 and 1997 evaluates both early (6 months) and long-term (average, 2.5 years) outcome after PS in combination with decompression arteriolysis of the radial and ulnar arteries proximal to the wrist. When preoperative digital blood flow was inadequate based on noninvasive vascular studies and major inflow occlusion was present, vascular reconstruction was also performed when feasible. At early review, significant improvement in ischemic digital pain and moderate improvement in cold intolerance resulted in eight hands, and at final follow-up, this was sustained in seven hands. Preoperatively, digital ulcerations were present in six hands. After digital debridement and/or amputation, all wounds healed, but in one patient with bilateral disease who continued to smoke, ulcerations recurred without the need for subsequent surgery. Five of six patients were no longer dependent on narcotic analgesics, but use of vasodilator medication did not change. Five of six patients claimed significant improvement in the quality of life after surgery and reported that they would undergo the surgery again. PS in combination with radial and ulnar arteriolysis appears to be efficacious at both early and long-term review. When major inflow occlusion exists and digital blood flow is compromised, vascular reconstruction is recommended if possible. We review our treatment protocol in this complex population of patients.

Surgery in patients with systemic sclerosis of the hand

Systemic sclerosis of the hand is an uncommon form of arthritis that can cause significant functional loss in the hand. It poses serious problems for the surgeon because of the diminished circulation of the digits. The tightness of the skin and joint stiffness that are characteristic of this condition make restoration of function difficult. Calcinosis, which is common in patients with systemic sclerosis of the hand, can be treated by excision or curettage. Patients with severe deformities of the digits and thumb often require fusions to improve grasp. Joint replacements with implants are not as successful in patients with systemic sclerosis as they are in patients with rheumatoid or degenerative arthritis. There have been recent attempts to improve the circulation to the fingers by sympathectomy or by vein grafts. These techniques, however, provide only temporary improvement and do not prevent or correct the severe digital and thumb deformities associated with this disease.

Ischaemia of the index finger and thumb secondary to thrombosis of the radial artery in the anatomical snuffbox

We report on nine patients who presented with spontaneous ischaemia of the index finger and thumb over an 11 year period. Arteriography revealed thrombosis of the radial artery in the region of the anatomical snuffbox with evidence of digital artery embolization in each. None had suffered direct trauma to the area or had a demonstrable proximal source for thrombus. While the cause of radial artery thrombosis in our patients in not entirely clear, local inflammation and/or systemic disease may predispose to this entity.

Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma

Arterial spasm due to exaggerated sympathetic response is an important mechanism for Raynaud's phenomenon in scleroderma associated often with periadventitial scarring. The results of cervical sympathectomy have been unsatisfactory in the upper limb because of additional sympathetic pathways. Flatt therefore devised a distal sympathectomy by stripping the vessels of their adventitia over a short length of artery. The results of this operation were found by Wilgis in a large series to be poor in patients with scleroderma. A radical distal microarteriolysis including adventitia and surrounding scar is described and the results in 13 patients, 11 with scleroderma, are reported. Minimum follow-up is one year. All patients had relief from pain at rest and healing of painful ulceration. Mild recurrence of small ulcers was seen in only four patients.

Treatment of systemic sclerosis

Proper classification of patients into diffuse cutaneous and limited cutaneous subsets and the anticipation of complications are the keys to the management of subjects with systemic sclerosis (scleroderma). Patients with early diffuse disease and rapidly progressive skin thickening are at highest risk of developing serious disease of the internal organs (intestine, lung, heart, kidney) and should be considered for disease modifying treatment. The targets of the disease and sites of possible intervention are vascular endothelium (vasoprotective agents), mononuclear cell subsets (immunosuppressive agents), and fibroblasts (colchicine, D-penicillamine). A number of new agents with sound scientific rationale are currently undergoing therapeutic trials. Much can be done to improve the lifestyle of those with scleroderma. The most dramatic recent development is the ability to reverse kidney disease by the prompt use of angiotensin converting enzyme inhibitors and modern methods of renal dialysis and transplantation. Scleroderma is not a hopeless disease.

Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis

Fifty consecutive patients with acute and chronic ischemia of the hand were investigated by Allen testing, Doppler ultrasound, digital plethysmography, and angiography over a 4-year period. The pathophysiologic mechanism responsible for the ischemia was determined to be emboli in 6%, vasospasm in 10%, thrombosis or "sludging" in 28%, occlusive disease in 26%, and occlusive disease associated with either vasospasm or external compression in 30%. Ten patients required emergency medical treatment with intraarterial streptokinase, intravenous heparin, or dextran 40 and continuous stellate ganglion blocks, and three patients required emergency microsurgical revascularization because of radial artery thrombosis. Patients with chronic ischemia of the hand were maintained on nifedipine, 30 to 60 mg daily, and pentoxifylline, 1200 mg daily. Seven patients underwent digital sympathectomy and 14 patients underwent microsurgical revascularization as prophylactic procedures for chronic digital ischemia. Amputations were required in 18 patients because of end-stage gangrene. Long-term follow-up revealed a 20% incidence of recurrent digital ulcerations. There have been six deaths during follow-up, five of them due to myocardial infarction; this reflects the underlying systemic arteriopathy in many of these patients.