Long-term results of ulnar and radial reconstruction with interpositional grafting using the deep inferior epigastric artery for chronic hand ischemia

Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan-Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

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.

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.