Palmar Arch Revascularization for Arterial Occlusion of the Distal Upper Extremity

ABSTRACT

During a period of nine years, 10 patients, ages 42 to 66 years (55 ± 7, mean ± SD) underwent upper extremity bypass for ischemic changes to the hand not responsive to conservative management. Patients were referred from the vascular department at the authors' institution. Preoperative angiograms were performed and attempts at angioplasty or intravenous attempts to dissolve clots were carried out (with tissue plasminogen activator-tPA) when appropriate. Patients with persistent upper extremity ischemia and an obvious occlusion with reconstitution in the hand were candidates for upper extremity bypass to the palmar arch. All patients had upper extremity bypasses performed with reverse saphenous vein grafts. The proximal anastomoses (end-to-side) were performed by either the vascular or plastic surgery team, while all distal anastomoses (end-to-side) were performed by plastic surgery team microscopic magnification to the deep or superficial palmar arch. Postoperative follow-up ranged from 3 months to 3 years. The bypass graft to the hand resulted in improved pain and resolution of tissue ischemia in all cases. Patients with preoperative ulcers were completely healed by 3 months. The results are in accordance with previous studies demonstrating that improved blood flow afforded by the procedure can improve the healing of recalcitrant ulcers and mitigate the symptoms of ischemic changes. In addition, end-to-side anastomosis to the palmar arch offers significant advantages, in that the continuity of the arch is maintained with all possible outflow vessels, and the problems associated with size discrepancy in the anastomosed vessels are eliminated.

KEYWORDS

Palmar arch revascularization - correction of gangrene in digits - jump graft from wrist to palmar arch

REFERENCES

• 1 Koman L A, Ruch D S, Aldridge M et al.. Arterial reconstruction in the ischemic hand and wrist: effects on microvascular physiology and health-related quality of life.  J Hand Surg. 1998;  23a 773-782
• 2 Ruch D S, Aldridge M, Holden M et al.. Arterial reconstruction for radial artery occlusion.  J Hand Surg. 2000;  25A 282-290
• 3 Guzman-Stein G, Schubert W, Najarian D W et al.. Composite in situ vein bypass for upper extremity revascularization.  Plast Reconstr Surg. 1989;  83 533-536
• 4 Pederson W C, Woodward C, Hermansdorfer J. Arterialization of the venous system for the treatment of end-stage ischemia of the upper extremity.  J Reconstr Microsurg. 1996;  12 414-417
• 5 Goldsmith H S. Salvage of end-stage ischemic extremities by intact omentum.  Surgery. 1980;  88 732-736
• 6 Coleman W L, Tsai T, Kleinert J M. Who really needs digital sympathectomy?. In: Proceedings of the American Society of Reconstructive Microsurgery; September 12-13 1987 San Antonio, TX; 39
• 7 Flatt A. Digital artery sympathectomy.  J Hand Surg. 1980;  5A 550-556
• 8 O'Brien B M, Kumar P A, Mellow C G et al.. Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma.  J Hand Surg. 1992;  17a 447-452
• 9 Merritt W H. Comprehensive management of Raynaud's syndrome.  Clin Plast Surg. 1997;  24 133-159
• 10 Jones N F. Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis.  J Hand Surg. 1991;  16A 1074-1983
• 11 Pederson W C. Revascularization of the chronically ischemic hand.  Hand Clinics. 1999;  15 629-642