Upper extremity bypass grafting for limb salvage in end-stage renal failure

Refining Treatment Strategies in Patients With Fingertip Wounds and End-Stage Renal Disease

BACKGROUND

Individuals with end-stage renal disease (ESRD) and fingertip wounds are at high risk of poor wound healing, ultimately requiring amputations. Optimal performance of upper extremity amputation (UEA) in patients with ESRD is important to decrease complications and minimize total operative procedures needed. This study evaluated outcomes of UEA in patients with ESRD and described risk factors predisposing patients to complications.

METHODS

A retrospective analysis of patients receiving nontraumatic UEA for fingertip wounds was conducted, stratified by patients with and without ESRD. Demographics, comorbidities, complications, and hospital course were analyzed between groups for differences. Subanalysis of patients with ESRD was conducted to characterize operative course and predictors of complications.

RESULTS

A total of 132 patients were included, 106 controls and 26 with ESRD. Compared with controls, patients with ESRD required more amputations (P < .001) and total operations (P < .001) to achieve wound healing. Patients with ESRD experienced higher rates of postoperative complications (P < .001). Predictors for complications in patients with ESRD were comorbid diabetes (odds ratio [OR]: 45; 95% confidence interval [CI], 1.7-1226.9), vascular disease (OR: 30; 95% CI, 2-441.8), arterial calcification (OR: 18; 95% CI, 1.56-207.5), and presence of a hemodialysis shunt in the affected arm (OR: 18; 95% CI, 1.56-207.5). Within patients with ESRD, initial amputation at, or proximal to, the metacarpophalangeal joint (MCPJ) led to fewer amputations (1.2 vs 2.19, P = .04) and fewer total operative procedures (4.1 vs 6.6, P = .03), compared with initial amputation distal to the MCPJ.

CONCLUSION

In nontraumatic fingertip wounds, patients with ESRD had worse operative outcomes than patients without ESRD. More aggressive management of fingertip wounds using earlier and more proximal initial amputations may expedite wound healing in certain high-risk patients with ESRD.

In Situ Bypass from the Brachial to Radial Artery in the Anatomical Snuffbox for Limb Salvage in End-Stage Renal Disease

Diabetes and renal failure frequently involved in small vessel arteriopathy. With medical advancements, those patients survive longer with an increasing incidence of resultant arterial occlusive disease affecting the distal upper extremity (UE). In patients with ulcers or gangrene in the distal UE, bypass surgery is often complicated by severe atherosclerosis with calcification, resulting in poor distal anastomosis quality. Here we report a patient with a fingertip gangrene who were successfully treated with in situ bypass from the brachial artery below the elbow to the radial artery in the anatomical snuffbox under local anesthesia. Bypass graft patency was maintained during the 18-month follow-up. If the forearm cephalic vein and radial artery in the anatomical snuffbox are of adequate quality, in situ bypass to radial artery in the anatomical snuffbox may be a useful option for limb salvage in selected patients.

Endovascular management of critical hand ischemia by 'palmar arch loop' technique

INTRODUCTION

Critical hand ischemia with advancing gangrene of digits requires urgent intervention to salvage as much tissue as possible. The purpose of this study was to evaluate the efficacy of "palmar arch loop" technique for endovascular management of critical hand ischemia by establishing inline flow to the palmar arch via both radial artery and ulnar artery, in patients with failed antegrade recanalization. To the best of our knowledge, this is the first case series evaluating the efficacy of "palmar arch loop" technique, with retrograde percutaneous transluminal angioplasty of the involved radial artery and/or ulnar artery.

MATERIAL AND METHODS

We retrospectively investigated 10 patients (60% female; mean age 42 ± 18 years; mean time of presentation post-acute event 24 ± 11 days) with critical hand ischemia undergoing endovascular intervention using "palmar arch loop" technique at a single center in northern India between April 2017 and March 2019. All patients were followed up at regular intervals (weekly for a month, fortnightly for 3 months, and then at 6 and 12 months) with clinical assessment and SpO₂ measurement. Study end points were technical success rate, hand healing, and primary patency rate at one year.

RESULTS

Causes for critical hand ischemia were iatrogenic injuries due to inadvertent intra-arterial injection in 50% (n = 5) and thromboembolic events in 50% patients (n = 5). Vessels involved were: both radial artery and ulnar artery along with the PA in 50%; radial artery and palmar arch in 30%; ulnar artery and palmar arch in 20%. All of them had total occlusion of the involved vessel (>2/3rd of total length) with occlusion/diffuse disease of palmar arch as well; 70% technical success rate was achieved ensuring inflow to palmar arch via both the arteries with improved flow distally to the common and proper digital arteries. Retrograde percutaneous transluminal angioplasty of radial artery in 50% (n = 5) and ulnar artery in 20% (n = 2) was done successfully by looping the guidewire across the palmar arch; 90% showed subjective improvement in pain with healing of the lesions and/or formation of clear line of demarcation with reversal of pregangrenous changes proximally. Out of the eight patients with gangrene of fingers, three underwent minor amputation of the gangrenous digits and five underwent auto-amputation of the gangrenous tissue with complete healing of the stump. Primary patency rate was 85.7% at one year. There was no access site-related complication or mortality in the follow-up period.

CONCLUSIONS

Endovascular management of critical hand ischemia by "palmar arch loop" technique is an efficient technique to deal with occluded forearm vessels, particularly when antegrade recanalization fails. This technique, with good technical success and patency rates, is potentially a unique tool in the endovascular armamentarium for salvaging hand.

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique.

Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations.

Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation.

Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Small Saphenous Vein and Arm Vein as Bypass Grafts for Upper Extremity Ischemia

BACKGROUND

Bypass in the upper extremity is a rare procedure mainly performed for chronic ischemia, trauma, or hemodialysis access complications. Feasibility and success of use of the arm vein and small saphenous vein (SSV) for autologous vein bypass have been reported in peripheral artery bypass procedures. There are very few reports on the use of alternative veins in upper extremity bypass. We report our experience with arm vein and SSV as a graft source in upper extremity arterial disease.

METHODS

Retrospective analysis of a consecutively collected case series in an academic tertiary referral center from January 2010 to February 2018. Study end points were primary patency, secondary patency, limb salvage, and survival.

RESULTS

In total, 47 patients were treated with upper extremity bypass either using the SSV (n = 17) or arm veins (n = 30). Indications were either acute (n = 12) or chronic ischemia (n = 35) caused by acute (n = 8) and chronic (n = 9) trauma, sequela of iatrogenic interventions (n = 4), peripheral artery disease (n = 14), thrombangiitis obliterans (n = 3), and dialysis-access-related complications (n = 9). An arm vein was used in 30 and the SSV in 17 patients. Primary patency after 12 months was 87% with the SSV and 75% with an arm vein (P = 0.8) and 63% and 75% after 36 months (P = 0.9). Secondary patency were 100% with an arm vein and 100% with the SSV after 36 months (P = 0.4). One patient had to undergo major amputation and 2 minor amputations.

CONCLUSIONS

Arm vein revascularization using the primarily arm vein or SSV as a bypass conduit can be performed with reasonable mortality and morbidity rates and provide good results comparable with the greater saphenous vein.

Outcomes of Endovascular Therapy for Upper Extremity Peripheral Artery Disease With Critical Hand Ischemia

PURPOSE

To investigate the clinical outcomes of endovascular therapy (EVT) for upper extremity peripheral artery disease (PAD) with critical hand ischemia (CHI).

METHODS

A subanalysis was performed of multicenter registry data on 36 consecutive patients (mean age 65.7±10.3 years; 19 men) who underwent EVT from January 2003 to December 2013 for angiographically diagnosed de novo upper limb PAD with CHI in 40 limbs. Fifty percent of patients had diabetes, and two-thirds were on hemodialysis. Technical success of EVT was straight-line flow to the hand and final residual diameter stenosis ≤50% for balloon angioplasty alone and ≤30% without flow-limiting dissection for subclavian artery stenting. The primary outcome was 12-month amputation-free survival [AFS; freedom from a composite of major (above-the-wrist) amputation and death]. The 12-month secondary outcomes were overall survival, limb salvage, freedom from major adverse limb events (MALE; major amputation or any repeat revascularization of the limb), and wound healing (complete epithelialization without death or major amputation).

RESULTS

Initial success was achieved in 87% (35 of 40 limbs); 1 patient experienced puncture site problems, and 3 (8%) of 36 patients (4 treated limbs) died within 30 days. Hand symptoms were alleviated in 37 (92%) limbs. The mean follow-up was 26.8±27.8 months. Seven fingers (5 limbs) underwent phalanx amputations and 2 limbs had an amputation above the wrist. Complete wound healing was achieved in only 5 (19%) of 26 surviving patients at 12 months. At 1 year, the Kaplan-Meier estimates for AFS, overall survival, limb salvage, and freedom from MALE were 56.4%, 59.4%, 93.1%, and 78.5%, respectively. Univariate analysis revealed that the predictors of AFS at 1 year were diabetes (p=0.03), hemodialysis (p<0.001), PAD (p=0.003), and the presence of a wound (p<0.001). During follow-up, 20 (56%) patients died; a cardiovascular cause accounted for 40% of deaths.

CONCLUSION

Endovascular therapy for upper limb PAD with CHI was technically successful and alleviated symptoms in the majority of cases, but the prognosis of patients with CHI was extremely poor in real-world clinical practice.

Angioplasty of forearm arteries as a finger salvage procedure for patient with end-stage renal failure

Due to the relatively low metabolic demand and extensive collaterals of the upper limb, peripheral arterial disease seldom leads to tissue loss, except in patients with end-stage renal failure (ESRF), rheumatologic diseases, Raynaud's disease, frostbites, or distal emboli. We report a case of a 51-year-old lady with ESRF who presented to our tertiary referral vascular center with infected gangrene of her right ring finger. Duplex ultrasound showed that her forearm arteries were severely diseased. Digital subtraction angiogram showed severe multilevel stenoses/occlusions in her forearm radial and ulnar arteries. These lesions were successfully angioplastized with 2 mm × 25 mm angioplasty balloon. Completion angiogram showed good radiological results with some post-dilatation spasm which improved with intra-arterial glyceryl trinitrate. The sepsis improved after revascularization, and the distal phalanx was allowed to self-demarcate with dressings and autoamputate with good clinical results. Our case illustrated that even in delayed setting, patients could still benefit from specialist vascular care with a combination of expert care and angioplasty of forearm arteries, with successful salvage of her finger.

Upper limb ischemic gangrene as a complication of hemodialysis access

Upper limb ischemia is a well-recognized complication of dialysis access creation but progression to gangrene is uncommon. We report a case of upper limb ischemic gangrene and discuss the lessons learned during the management of this case. Clinicians must be vigilant for this complication and they should be reminded that it requires urgent management to prevent tissue loss.

Symptomatic radial artery thrombosis successfully treated with endovascular approach via femoral access route

Radial access has been increasingly utilized for coronary intervention due to higher safety profile in comparison to femoral access site with lower bleeding rate. Radial artery occlusion is not uncommon with radial access site. This usually does not lead to any harm due to ulnar artery collaterals that are sufficient to prevent hand ischemia and is usually left alone. However, in the case of significant hand ischemia, treatment is often necessary. We are reporting an interesting case of symptomatic radial artery thrombosis leading to arm ischemia that was successfully treated percutaneously using femoral access. Using femoral access for radial artery intervention has not been reported previously. This case is followed by review of the literature.

Intra-arterial autologous bone marrow cell transplantation in a patient with upper-extremity critical limb ischemia

Induction of therapeutic angiogenesis by autologous bone marrow mononuclear cell transplantation has been identified as a potential new option in patients with advanced lower-limb ischemia. There is little evidence of the benefit of intra-arterial cell application in upper-limb critical ischemia. We describe a patient with upper-extremity critical limb ischemia with digital gangrene resulting from hypothenar hammer syndrome successfully treated by intra-arterial autologous bone marrow mononuclear cell transplantation.

Angioplasty of ulnar or radial arteries to treat critical hand ischemia: use of 3- and 4-French systems

OBJECTIVES

The aim of this preliminary study is to report the results of catheter-based treatment for isolated distal upper extremity artery disease with CHI.

BACKGROUND

Critical hand ischemia (CHI) is a rare but potentially devastating condition.

METHODS

The study consisted of five critically ischemic hands (Rutherford category 4: 2, Rutherford category 5: 3) in four patients undergoing catheter intervention for isolated distal upper extremity artery disease between November 2007 and April 2009.

RESULTS

Balloon angioplasty via an antegrade brachial approach was performed with a 3Fr or 4Fr sheath to achieve the principal endpoint of the establishment of one straight-line flow to the palmar arch. All patients had end-stage renal disease requiring chronic hemodialysis. The target vessels were the ulnar artery in four cases, the radial artery in one, and the palmar arch in two. Four cases had a stenotic lesion and one had chronic total occlusion. Technical success was achieved in all cases without complications, and skin perfusion pressure of the hand improved significantly from 39 ± 20 to 52 ± 16 (P = 0.019) on the palmar side and from 40 ± 18 to 60 ± 29 on the dorsal side (P = 0.046). Clinical success was achieved in all cases during a mean follow-up period of 11 ± 8 (2-19) months.

CONCLUSIONS

Percutaneous angioplasty using contemporary dedicated devices could be a potentially useful option for CHI patients with isolated distal upper extremity artery disease.

Bypass surgery for the treatment of upper limb chronic ischaemia

OBJECTIVES

This study aims to evaluate the results and complications of surgical arterial revascularisation of the upper limb for treatment of chronic ischaemia using infrabrachial bypass. Results of limb salvage and follow-up with graft patency are analysed.

DESIGN

This study is a retrospective analysis of 23 patients affected by chronic upper limb ischaemia and treated by surgical bypass.

MATERIALS AND METHODS

We retrospectively analysed 23 patients with upper limb ischaemia treated between January 1998 and January 2008, by means of bypass graft revascularisation. After surgical revascularisation, eight patients (35%) with digital gangrene underwent minor amputations during the same surgical session, or within the following few days. Postoperatively, patients were followed up at regular intervals of 1, 3 and 6 months, and every 6 months thereafter, both clinically and with a duplex ultrasound scan.

RESULTS

The mean 34 months' follow-up was 96% complete. Life table analysis revealed a primary patency of 82.6% and secondary patency of 91.3%. Limb salvage was 100%. During the follow-up period, four patients sustained graft occlusion and, of these, two underwent re-do revascularisation with success.

CONCLUSIONS

We believe upper limb bypass surgery represents a valid treatment in this clinical setting, both for limb salvage and for relief of symptoms.

Arterial Revascularization for Upper Extremity Ischemia in Patients with Chronic Kidney Disease

Surgical revascularization of the upper extremity is uncommon, comprising only 4 to 18 per cent of all vascular surgical interventions. Patients with renal failure have higher rates of atherosclerotic cardiovascular and peripheral arterial disease resulting from chronic inflammation, endothelial damage associated with hemodialysis, and vascular trauma. Upper extremity arterial disease with chronic ischemia may be underrecognized in these patients. We reviewed our experience with upper extremity revascularization in patients with renal failure presenting with chronic ischemia. Four patients with longstanding chronic kidney disease developed chronic severe ischemia affecting the forearm or hand. All had previous dialysis access in the symptomatic arm, although none had a functional ipsilateral access at the time of presentation. All patients had successful revascularization with resolution of symptoms and patent bypass grafts at follow up. There was one death 4 months postoperatively and one patient has not returned for follow up. Patients with renal failure with symptomatic upper extremity arterial occlusion should be considered for revascularization of the infrabrachial arteries.

Bypass for chronic ischemia of the upper extremity: Results in 20 patients

OBJECTIVE

Chronic ischemia of the upper extremity requiring surgical revascularization is an uncommon condition. We analyzed modes of presentation, methods of operative repair, and follow-up in all consecutive patients with chronic ischemia of the upper extremity requiring arterial bypass.

METHODS

Data prospectively entered into a vascular registry was retrospectively analyzed for all patients undergoing upper extremity arterial bypass from January 1, 1990, to June 30, 2003. Simple thromboembolectomy procedures and bypasses to an outflow target more proximal than the brachial artery were excluded.

RESULTS

We identified 20 patients. Their mean age was 57 years, and 11 (55%) were women. Eight (40%) had diabetes, and five (25%) had renal insufficiency. Indications included exercise intolerance in 11 patients (55%), tissue loss in six (30%), and rest pain in three (15%). The etiology of ischemia was atherosclerosis in seven patients (35%) and complications of iatrogenic or civilian trauma in 13 (65%). The brachial artery was used as the inflow in 13 patients (65%), the axillary in six (30%), and the ulnar in one (5%). Conduits used included the great saphenous vein in 11 patients (55%), arm vein in 7 (35%), and prosthetic in 2 (10%). Outflow targets included the brachial artery in 12 patients (55%), the radial in five (25%), and the ulnar in three (15%). There were no perioperative deaths. One graft (5%) occluded <or=30 days of surgery. Mean follow-up was 12 months. Mean survival after bypass was 62 months. Patency at 1 and 3 years was 85%. Two patients had associated minor amputations (a finger and a partial hand). Limb salvage rate was 100%.

CONCLUSION

Although upper extremity ischemia is rare, results for upper extremity bypass are excellent and superior to those reported for lower extremity ischemia. These results may reflect the indications, which differ considerably from those for lower extremity bypass, with the most being performed for complications of trauma.

Successful Percutaneous Angioplasty and Stenting of The Radial Artery in a Patient with Chronic Upper Extremity Ischemia and Digital Gangrene

PURPOSE

To report percutaneous treatment of a chronic radial artery occlusion in a multimorbid patient with ischemic tissue loss.

CASE REPORT

A 62-year-old man with multiple comorbidities, including renal failure and severe coronary artery disease, presented with painful, ulcerated lesions of his right hand. He has severe peripheral vascular disease, with a history of 4 digital amputations of the left hand, a right above-knee amputation, and a left femoral to peroneal artery bypass. Arteriography demonstrated chronic occlusion of the radial and ulnar arteries, with a patent interosseous and collateral flow to the distal radial artery filling the palmar arch. Angioplasty and stenting of the radial artery was performed, relieving the patient's symptoms and allowing the lesions to heal.

CONCLUSION

Percutaneous intervention can treat severe upper extremity ischemia with gangrene in patients with severe chronic ischemia and multiple comorbidities.