Arterialization of the Venous System of the Hand

Simultaneous bilateral distal venous arterialization between redial artery and cephalic vein in dorsal hand for Raynaud's phenomenon in both hands: A case report

Raynaud's phenomenon (RP) is characterized by episodic vasospasm in peripheral vessels and ischemia of the fingers. Venous arterialization is thought to induce neovascularization and increased oxygen tension. In this report, we describe a patient with RP in the fingers of both hands in whom venous arterialization achieved an acceptable result in both hands. The patient was a 62-year-old woman with a 10-year history of worsening pain and cold sensation in the tips of the index, middle, ring, and little fingers on both sides. The venous arterialization procedure was performed on both hands simultaneously at the level of the anatomical snuff box between radial artery and cephalic vein in dorsal hand. There was no need for valvectomy in the level of hands. To prevent development of the steal phenomenon in the arterialized veins, the superficial basilic and median veins of the forearm were ligated via 1 cm skin incisions. The pain and cold sensation in the fingertips of both hands remained decreased, and the nonhealing ulcers on the fingertips healed without the need for amputation. The observation period was 14 months, and the surface temperature of the fingers was increased after venous arterialization, as was the temperature of the palm and forearm. There was no problem when administering intravenous infusion into the forearm on either side postoperatively. The case showed venous arterialization was effective for RP without increasing intravenous pressure in the affected limb, and further investigation is necessary.

A review of percutaneous deep vein arterialization for the treatment of nonreconstructable chronic limb threatening ischemia

Peripheral arterial disease is estimated to affect more than 200 million people worldwide with some patients progressing to chronic limb threatening ischemia (CLTI). Patients with CLTI have extremely high rates of amputation and associated increases in morbidity and mortality. There is a subset of patients with CLTI that have no available options for revascularization due to factors such as the absence of distal target vessels or adequate conduit for surgical revascularization. Percutaneous deep vein arterialization can be used in patients with nonreconstructable CLTI. In this review article, we discuss patient selection, methods, and techniques of deep vein arterialization. In addition, results from studies evaluating the use of percutaneous deep vein arterialization, such as the Alkmaar (The Netherlands), Leipzig (Germany), Paris (France), and Singapore (ALPS) multicenter center study and the prospective, multicenter, single-arm, early feasibility (PROMISE I) trial, are highlighted. These results have been encouraging with improved rates of limb salvage and wound healing reported, suggesting percutaneous deep vein arterialization may be beneficial in treating patients with CLTI.

Arterialization of the Venous System for Acute and Chronic Ischemia of the Hand: A Case Series With Prospective Duplex Ultrasound Assessment

Background: Ischemia of the hand is a debilitating condition. In many cases, the cause of ischemia is diffuse atherosclerosis with no distal vessels available for bypass. In these situations, options are limited to restore perfusion, and there is a potential role for arterialization of the venous system to relieve ischemic pain and avoid amputation. Methods: This is a retrospective review of all patients at our institution who underwent arterialization of the venous system between 2010 and 2014 by 4 surgeons for acute or chronic ischemia of the upper extremity not amenable to bypass procedures. Indications, preoperative and postoperative findings, and the requirement for future digital amputations were recorded. The patients were then evaluated prospectively for the patency of arteriovenous anastomosis and the pattern of perfusion by duplex ultrasound studies. Results: Eight patients with 10 upper extremities underwent arterialization of the venous system. All patients with chronic ischemia went on to heal their ischemic ulcerations with relief of rest pain and avoided amputation. Eight upper extremities had arterial Doppler and duplex ultrasound signals showing arterialized dorsal veins demonstrating flow from the dorsal veins heading volar via the intrinsic compartments into the digital arteries. Conclusions: This study illustrates the successful use of arterialization of the venous system of the hand in both acute and chronic hand ischemia. It reports on prospective imaging and duplex ultrasound studies confirming patency of the anastomosis and objective evidence of distal arterial flow. Based on our experience, we believe that arterialization of the venous system may provide an effective salvage option in the setting where no distal bypass is available.

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.

Lymphaticovenular anastomosis and venous arterialization in coexisting Raynaud's phenomenon and lymphedema: A case report

Raynaud's phenomenon is highly prevalent in the general population. The optimal medical management for patients with severe Raynaud's phenomenon remains unclear. Venous arterialization (VA) may be considered as a salvage procedure when no distal vessels are available for vascular reconstruction. Surgical treatments for lymphedema, including lymphovenous anastomosis (LVA), are becoming popular alternatives to conservative therapy. Here, we report on a patient with comorbid primary Raynaud's phenomenon and lymphedema in whom both VA and LVA were performed. The patient was a 60-year-old woman with an edematous right upper limb and pain and cold sensitivity in the middle, ring, and small fingers that was refractory to medication. Indocyanine green lymphography and computed tomography angiography suggested coexistence of lymphedema and primary Raynaud's phenomenon. VA and LVA were performed to reduce the risks of cellulitis and amputation. Computed tomography angiography was performed regularly after surgery to examine the arterialized venous system and Doppler echography to search for developing branches. Five months later, three branches of the arterialized veins that flowed proximally at the level of the hand and wrist were ligated. By around 1 year after surgery, the lymphedema index in the affected upper limb had improved from 116 to 103 and the patient's numerical rating scale score for intractable pain and cold sensitivity had improved from 6-7 to 1-2. We believe that the combination of VA and LVA in the early stages of primary Raynaud's phenomenon and lymphedema was effective in this case.

An Unusual Case of Bilateral Upper Extremity Ischemia Caused by Forearm Vessel Fibromuscular Dysplasia

Fibromuscular dysplasia (FMD) is a nonatherosclerotic disease that generally affects medium-sized arteries. The distribution typically involves the renal, extracranial carotid/vertebral, and iliac arteries. FMD in other vascular beds is rare. We herein present the case of a 47-year-old female with rapid-onset bilateral digital ischemia. Initial differential diagnosis included vasospastic disorders and vasculitis. An upper extremity arteriogram was suggestive of ulnar and radial FMD. Percutaneous intervention was not successful, and the patient was managed conservatively with symptomatic improvement. This case highlights the important diagnostic and therapeutic considerations in patients with less common etiologies of upper extremity ischemia.

Revascularization options for terminal distal ischemia

Direct arterial bypass remains the best option in patients with terminal ischemia of the hand, if there is an adequate distal target vessel. In situ bypass is the procedure of choice in patients who are candidates for arterial bypass. Venous arterialization offers an option in patients in whom there is not adequate arterial runoff in the hand. Venous arterialization should be avoided in patients with significant wounds and/or active infection. In selected patients, microvascular omental transfer can offer an option for revascularization of the ischemic hand.

Perfusion Assessment with the SPY System after Arterial Venous Reversal for Upper Extremity Ischemia

Supplemental Digital Content is available in the text.

Background:

The timing and pattern of reperfusion following arterial- venous reversal (AVR) in patients with terminal ischemia of an upper extremity is not well understood.

Methods:

The current case series describes the timing and pattern of reperfusion observed in patients with terminal upper extremity ischemia who underwent AVR and repeated postoperative indocyanine green (ICG) angiography between 2004 and 2009. For all included patients, the SPY Near-Infrared Perfusion Assessment System permitted visualization of ICG-labeled blood flow for 60-second sampling periods at scheduled postoperative time points; outflow and rate and amplitude of inflow were objectively quantified with SPY-Q Analysis Toolkit image analysis software.

Results:

The series comprised 6 male patients (mean age, 46 years) who presented with upper extremity ischemia related to hypothenar hammer syndrome (n = 2), embolism with patent foramen ovale (n = 2), atherosclerosis (n = 1), and avulsion amputation of the thumb (n = 1); the patient with the avulsion amputation was diagnosed with thromboangiitis obliterans at the time of replantation. AVR was successful in all 6 patients. In 5 of 6 patients, ICG angiography and SPY-based visualization/quantification showed that venous outflow and arterial inflow gradually normalized (versus unaffected digits) between postoperative days (PODs) 0 and 3 and was maintained at long-term follow-up (≥3 months); for the patient who underwent thumb replantation, perfusion normalized between POD 3 and month 5 follow-up.

Conclusions:

AVR effectively reestablished blood flow in patients with terminal upper extremity ischemia. ICG angiography with SPY technology revealed that, in most cases, kinetic curves, timing, and patterns of perfusion gradually normalized over several PODs.

Revascularization of the ischemic hand with arterialization of the venous system

Chronic ischemia in the upper extremity is a challenging condition for both patients and surgeons. When ischemia reaches a critical level, tissue loss ensues, which results in necrosis of fingers at various levels. Amputation of necrotic digits, without addressing the etiology of the necrosis, often results in wound-healing problems and more proximal amputations. The purpose of this report was to describe a surgical technique that improves vascular supply to the hand and allows for healing of the amputation sites and relief of pain through arterialization of the venous system.

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.

Replantation of a degloved hand with added arteriovenous anastomoses: report of two cases

Revascularization of the degloved skin is generally accepted as the best option for the management of totally degloved hands. Nevertheless, the selection of vessels for anastomoses is usually difficult in this situation, and insufficient perfusion of the degloved hand skin is common after arterial repair. We present 2 cases of patients who sustained totally degloved hand injuries. Favorable outcomes of replantation were achieved with added arteriovenous anastomoses between the dorsal veins of the degloved hand skin and the digital arteries.

Long-term successful outcome of severe hand ischemia using arterialization with reversal of venous flow: case report

The management of unreconstructible vascular lesions in the hand is a challenge with limited options for treatment. After 22 years of hand ischemia, involving management with reverse interpositional vein grafting, periarterial sympathectomy, and partial finger amputations, a 62-year-old man underwent arterialization of the venous system of the hand for unreconstructible distal vascular lesions as a salvage procedure. At 7-year follow-up, the patient is pain-free with good functional and health-related quality of life outcomes and no further amputations. This procedure may be considered as a salvage alternative to prevent additional amputation in selected patients.