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Upper Extremity Arterial Bypass Distal to the Wrist
Anatomy and Technique SECTION EDITOR: Andris Kazmers, MD MEDICAL ILLUSTRATIONS: Richard A. Gersony, MFA
Upper Extremity Arterial Bypass Distal to the Wrist Ronald L. Dalman, MD, Palo Alto and Stanford, California
Since the initial report of Garrett et al.1 in 1965, several surgeons have published their experience with upper extremity revascularization using autogenous vein.2-7 With time and experience, these techniques have proven useful for distal bypass procedures at or below the wrist.8 Interposition vein grafting is the reconstructive method of choice following resection of posttraumatic aneurysms of the ulnar artery, a condition first described by von Rosen9 and termed the hypothenar hammer syndrome (HHS) by Conn and associates.10 Originally recognized only in machinists, carpenters, and mechanics, the HHS has more recently been described in many occupational and vocational situations, including professional and amateur athletes involved in basketball, badminton, golf, squash, and mountainbiking.11,12 Patients with the HHS are typically young and productive members of society. Prior to the wide acceptance of interposition vein grafting in the vascular, plastic, and hand surgery literature, ligation was the most commonly recommended procedure to prevent further embolization and, ultimately, digital amputation. Increased patient survival with end-stage renal disease (ESRD) is creating a larger cohort of patients with severe hand and finger ischemia.13,14 The etiologic backgrounds for these symptoms are diverse and include arterial thrombosis or steal related to dialysis access procedures,15-18 accelerated atherosclerosis, and diffuse arterial calcification and occlu-
From the Vascular Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA. Correspondence to: R.L. Dalman, MD, Vascular Surgery Section, Surgical Service (112), VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. 550
sion that occur in some cases as part of a condition termed calciphylaxis.19 Clinical presentation ranges from digital rest pain and ulceration to gangrene, and the condition occasionally necessitates digital amputation and, in severe cases, hand amputation. As is the case with posttraumatic ulnar aneurysms, the ischemic sequela of ESRD are often effectively treated by autogenous venous arterial reconstruction at or distal to the wrist. Because ischemic hand and finger symptoms are a common patient complaint, familiarity with the anatomic and technical details required for successful distal upper extremity arterial reconstructive procedures is necessary. Arterial perfusion to the hand is typically supplied by both the ulnar and radial arteries (Fig. 1). Most commonly, the ulnar artery is the largest artery crossing the wrist. Considerable overlap exists between the deep (radial) and superficial (ulnar) palmar arches. Many anomalous conditions exist, including incomplete superficial or deep arches, absence of a deep palmar branch of the ulnar artery, or superficial palmar branch of the distal radial artery resulting in a lack of collateral flow between the two arches, fusion of the deep and superficial system, and absent or diminuative ulnar or radial arteries. The frequency of these anomalies varies, but they seem to occur more commonly in symptomatic patients. Finger discoloration or pain are the predominant symptoms experienced by HHS patients. Thrombosis of ulnar artery aneurysms may lead to occlusion, but more frequently chronic digital embolization gradually occludes the proper digital arteries of the second through fifth digits. HHS patients usually present with cyanotic or pale fingers, painful or nonhealing digital ulceration. Patients with ischemic sequela of ESRD usually present with more extensive hand and digital ischemia, typically not
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Fig. 1. Posttraumatic ulnar artery aneurysm located adjacent to the hamate bone. This hand has well developed superficial and deep palmar arches, with substantial collateral flow present between the two. Symptomatic hypothenar hammer syndrome patients frequently have less well developed collateral connections between the arches.
limited to one or two individual digits. Intolerance to cold is a frequent presenting symptom in both HHS and ESRD patients. It has been our practice in such patients to rule out autoimmune or other associated disease processes. These tests include a complete blood count, erythrocyte sedimentation rate, multi-chem panel, antinuclear antibody, serum protein electrophoresis, rheumatoid factor, cold agglutinin assay, and hepatitis serology. Under appropriate clinical circumstances, hypercoaguability testing may provide important additional information. During evaluation all patients also undergo noninvasive upper extremity vascular laboratory testing including Doppler analog pulse recording; brachial, radial, and ulnar pressure determination; and digital artery closure tesing after cooling (when appropriate to the patient’s symptoms).20,21 For diagnosis of HHS, and preoperative planning prior to arterial reconstruction in any ischemic patient, selective catheter-based contrast arteriography remains our imaging standard of choice. We have no experience with alternative imaging modalities such as magnetic resonance arteriography in these patients.11 Upper extremity arteriography in these patients is technically demanding; catheter posi-
tioning in the axillary artery is required for sufficient images, and care must be taken to avoid catheter contact with the arterial wall to avoid catheter induced vasospasm. Bilateral studies are required for precise definition of baseline anatomy in most patients. Hand warming, intraarterial vasodilators, and magnification views may also be required.22 We perform all distal upper extremity arterial procedures with loupe optical magnification. General or regional anesthesia may be used. Ulnar artery aneurysms generally occur at the point where the ulnar artery passes over the hamulus (or ‘‘hook’’) of the hamate bone just distal to the pisiform bone at the wrist (Fig. 2A). Treatment goals are twofold: improve distal perfusion and prevent further embolization to the digital arteries. Following aneurysm resection, digital circulation improves in most patients, with or without extraordinary measures such as intraarterial thrombolytic therapy during or prior to surgery.23 The ulnar nerve lies immediately medial to the artery in the same plane. Both artery and nerve course medial to the flexor digitorum superficialis tendons at the wrist, and pass superficial to the flexor retinaculum. The deep branch of the ulnar artery may be involved with the aneurysmal segment or be occluded. Frequently,
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Fig. 2. A Detail of posttraumatic ulnar artery aneurysm, located distal to the pisiform bone at the wrist and distal to the deep palmar branch of the ulnar artery, but typically proximal to or just involving the common digital artery of the 5th digit. B Operative exposure via longitudinal incision directly over the palpable ulnar artery pulse. C Schematic of the arteriographic appearance of
fusiform posttraumatic ulnar aneurysms. Frequently, the artery appears irregular or serpiginous; characteristically described as a ‘‘corkscrew’’ appearance. D Repair usually involves excision of the aneurysm, with E interposition repair with reversed autogenous vein. Ideally, dorsal foot vein F provides the appropriate size match.
however, the aneurysm begins at this level and extends distally to the bifurcation of the ulnar artery into the common palmar digital artery of the 5th digit and the superficial palmar arch. Exposure is typically obtained through a longitudinal wrist incision extending to the midportion of the palm directly over the ulnar artery (Fig. 2B). Ulnar artery aneurysms are usually not large (in diameter) but rather tortuous and fibrotic, with a characteristic ‘‘corkscrew’’ appearance present on arteriography (Fig. 2C). Following aneurysm excision, the ulnar artery is reconstructed with an end to end interposition graft (Figs. 2D and 2E). Reversed vein grafts are obtained from the dorsum of the foot (Fig. 2F) when available and of adequate caliber and quality. Alternatively, basilic or cephalic arm vein conduit may be more appropriate in individual patients. Back bleeding from the distal ulnar artery, the ulnar common digital artery, the superficial palmar arch and the distal radial artery is temporarily controlled with Heifetz aneurysm clips as
needed. All anastomoses are performed with 7-0 polypropylene or 8-0 PTFE suture in continuous fashion. The adequacy of repair is confirmed by intraoperative Doppler examination. The wound is usually closed with a single layer of interrupted cutaneous 4-0 nylon suture placed in simple running or interrupted vertical mattress fashion. After operation, these patients are treated with a bulky dressing and a volar splint to immobilize the wrist. Early postoperative graft monitoring is facilitated by oximeter probe placement on an appropriate digit. The dressing and splint are changed as needed and maintained in place for 14 days. The procedure itself is usually performed as an outpatient or day procedure, with a single night stay reserved for patients with anesthetic difficulties. No special antiplatelet, anticoagulant or hemorrheologic agents are routinely used in this patient population. After immediate surgical recovery and wound healing, long-term occupational or vocational modifications are made in recognition of the
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Fig. 3. A Ulnar-ulnar vein bypass graft using forearm inflow. Note relationship to flexor digitorum superficialis muscle. B Extensive forearm involvement may require inflow from the brachial artery just below the elbow. C The bicipital aponeurosis may need to be partially divided to optimize exposure.
increased susceptibility of the ulnar artery vein graft to the same degenerative changes that prompted aneurysm formation in the first place. Failure to avoid further injury may prompt re-thrombosis or aneurysm formation in the replacement vein graft.24 As previously mentioned, patients with ESRD usually have more extensive involvement of the fingers and hand than HHS patients and more severe ischemia as documented by noninvasive laboratory studies. Ulceration is more common, as is the co-existence of contralateral symptoms and signs of hand or finger ischemia. ESRD patients may also suffer from long-standing insulin-dependent diabetes, and as such are older (average age 45 versus 34 for HHS patients),8 and have extensive atherosclerotic and/or calcific changes present throughout the arteries of the forearm and hand. In ESRD or diabetic patients, a patent distal vessel with reasonable runoff into the superficial or deep palmar arch is necessary to develop and maintain a successful bypass. Determining the appropriate location for inflow prior to bypass may also be problematic.
Inflow may be obtained from the proximal radial or ulnar artery (Fig. 3A) for distal bypass, but in ESRD patients frequently a soft and clampable arterial inflow source is found only at the level of the brachial artery just distal to the elbow (Fig. 3B). Patent but calcific palmar arteries may have backbleeding controlled by intralumenal placement and gentle inflation of [2 Fogarty™ embolectomy catheters. For bypass procedures that extend from the antecubital fossa to the wrist or palm, sections of greater or lesser saphenous veins are most appropriate. Patent ipsilateral forearm hemodialysis access fistulas or shunts may present a particular challenge in these patients, especially when alternative sites for access are not readily available. Previously placed radial-antecubital vein shunts may be present in patients with distal radial artery occlusion (Fig. 4A) or in the setting of ulnar artery occlusion with a patent distal radial artery, producing hand ‘‘steal’’ symptoms proportionate to the fraction of radial artery flow diverted through the shunt. Retrograde radial artery flow distal to the radial artery
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Fig. 4. A Ischemic hand with functional ipsilateral radial-cephalic arteriovenous dialysis shunt. Both radial and ulnar occlusions are present, but flow continues through the radial artery to the level of the shunt B. Ideally, hand revascularization may be accomplished without sacrifice of the functional access site. C Revascularization based on proximal radial artery inflow, with inset showing level of incision and proximal anastomosis of the ultimate radial-radial bypass.
anastomosis is common.25,26 When associated with ischemic symptoms or signs, especially in the setting of forearm arterial occlusive disease, radial steal becomes pathologic27 and may be easily confirmed by duplex scanning in the noninvasive vascular laboratory. In the case outlined in Figure 4A, radial and ulnar artery occlusions are present, resulting in severe hand ischemia. In addition to the typical symptoms outlined above, these patients may also experience ischemic monomelic neuropathy, especially in the setting of pre-existing diabetic neuropathy. Ischemic monomelic neuropathy causes severe hand and forearm pain, paresthesias, and hypesthesia, and may not be reversible following revascularization.28 If ischemic symptoms co-exist with retrograde distal radial artery flow, the shunt may be removed as a simple definitive treatment. However, if distal radial and ulnar artery occlusions are also present, hand revascularization may be required regardless of the ultimate disposition of the shunt.29 Under these circumstances, an autogenous vein graft from the proximal radial or brachial artery to the distal
radial artery in the anatomic snuffbox (formed by the extensor pollicis brevis and longis tendons on the lateral aspect of the wrist) may suffice to relieve ischemia in the hand while maintaining viable ipsilateral hemodialysis access (Fig. 5). Bypass to the distal radial artery avoids re-operation near the inflow anastomosis of the dialysis access shunt and presumably minimizes the chance of bypass graft injury from hemodialysis cannulation. When the distal ulnar artery or superficial palmar arch are present and patent, they may represent more suitable bypass targets under these circumstances.
CONCLUSION Surgically correctable, noniatrogenic arterial lesions of the hand or forearm are an uncommon cause of chronic hand ischemia. At least 170 cases of ulnar artery aneurysm have been reported in the Englishlanguage literature since 1944.30-48 Other causes of hand and finger ischemia are encountered more frequently and include embolization from a car-
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Fig. 5. A, B Relationship of radial artery to the extensor aponeurosis and tendons which comprise the anatomic snuffbox on the dorsal surface of the arm. C Radial-radial reversed autogenous vein graft, with proximal anastomosis detailed in Figure 4C, and distal anastomosis within the anatomic snuffbox. D Completed revascularization, with inline pulsatile arterial flow restored to the deep palmar arch via radial-radial autogenous vein bypass grafting and continued patency of pre-existing dialysis access shunt.
diac49-52 or proximal noncardiac arterial source,53,54 atherosclerotic occlusive disease of the arteries proximal to the wrist without distal embolization,1-7 and brachial and radial occlusion after cannulation.1-7,19 Despite the relatively rare incidence of symptomatic arterial occlusive at or distal to the wrist, a growing number of these patients may be candidates for arterial bypass or resection and interposition. Good long-term symptomatic improvement and vein graft patency rates have now been reported by several groups with the use of the interposition vein grafting techniques described in this review.30,33,55 In HHS patients, interposition vein grafting has the benefit of preventing further embolization and in maintaining distal perfusion. In ESRD patients, fistula or shunt patency may be preserved while distal bypass grafting markedly improve finger or hand perfusion. Surgery for the HHS should be reserved for symptomatic patients; patients with asymptomatic thrombosis of ulnar artery aneurysms should not undergo resection and revascularization based
on the available data at this time. The overall natural history of asymptomatic ulnar aneurysms remains unknown. Patients with ESRD and/or diabetes should also be treated on a symptomatic basis. The role for long-term graft surveillance remains unknown at this time following treatment of either HHS or ESRD related ischemia. The distal nature of these bypasses does not appear to compromise performance or outcome, and we and others are choosing them with greater frequency and confidence.
REFERENCES 1. Garrett HE, Morris GC, Howell JF, Debakey ME. Revascularization of the upper extremity with autogenous vein graft. Arch Surg 1965;91:751-757. 2. Gross WS, Flanigan DP, Kraft RO, Stanley JC. Chronic upper extremity arterial insufficiency. Arch Surg 1978;113:419423. 3. Schmidt FE, Hewitt RL. Severe upper limb ischemia. Arch Surg 1980;115:1188-1191.
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4. Holleman JH, Hardy JD, Williamson JW, et al. Arterial surgery for arm ischemia. Ann Surg 1980;191:727-735.
24. Higgs PE, Weeks PE. Traumatic pseudoaneurysm in an ulnar artery vein graft. Plast Reconstruct Surg 1993;91:726-728.
5. Erlandson EE, Forrest ME, Shields JJ, et al. Discriminant arteriographic criteria in the management of forearm and hand ischemia. Surgery 1981;90:1025-1036.
25. Anderson CB, Etheredge EE, Harter HR, et al. Blood flow measurements in arteriovenous dialysis fistulas. Surgery 1977;81:459-461.
6. Willing RE, Cranley JJ, Krause RJ, Hafner CD. Obliterative arterial disease of the upper extremity. Arch Surg 1981;116: 1593-1596.
26. Duncan H, Ferguson L, Faris I. Incidence of the radial steal syndrome with Brescia fistula for hemodialysis: Its clinical significance. J Vasc Surg 1986;4:144-147.
7. McCarthy WJ, Flinn WR, Yao JST, et al. Results of bypass grafting for upper limb ischemia. J Vasc Surg 1986;3:741746.
27. Valji K, Hye RJ, Roberts AC, et al. Hand ischemia in patients with hemodialysis access grafts: Angiographic diagnosis and treatment. Radiology 1995;196:697-701.
8. Nehler MR, Dalman RL, Harris EJ, et al. Upper extremity arterial bypass distal to the wrist. J Vasc Surg 1992;16:633642.
28. Hye RJ, Wolf YG. Ischemic monomelic neuropathy: An under-recognized complication of hemodialysis access. Ann Vasc Surg 1994;8:578-582.
9. Von Rosen S. Ein Fall von Thrombose in der Arteria Ulnaris nach Einwirkung von Stumpfer Gewalt. Acta Chir Scand 1934;73:500-506. 10. Conn J, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery 1970;68:1122-1128. 11. Kreitner K-F, Duber C, Muller L-P, et al. Hypothenar hammer syndrome caused by recreational sports activities and muscle anomaly in the wrist. Cardiovasc Intervent Radiol 1996;19:356-359. 12. Applegate KE, Spiegel PK. Ulnar artery occlusion in mountain bikers. J Sports Med Phys Fitness 1995;35:232-234. 13. Wilkinson SP, Stewart WK, Parham DM, Guthrie W. Symmetric gangrene of the extremities in late renal failure: A case report and review of the literature. Q J Med 1988;252: 319-341. 14. Jones NF. Ischemia of the hand in systemic disease: The potential role of microsurgical revascularization and digital sympathectomy. Clin Plast Surg 1989;16:547-556. 15. Kinnaert P, Struyven J, Mathieu J, Vereerstraeten P, Toussaint C, Van Geertruyden J. Intermittent claudication of the hand after creation of an arteriovenous fistula in the forearm. Am J Surg 1980;139:838-843. 16. Ebeid A, Saranchak HJ. Banding of a PTFE hemodialysis fistula in the treatment of steal syndrome. Clin Exp Dialysis Aphersis 1981;5:251-257. 17. Dally P, Brantigan CO. Plethysmography and the diagnosis of the steal syndrome following placement of arteriovenous fistulae and shunts for hemodialysis access. J Cardiovasc Surg 1987;28:200-203.
29. Schanzer H, Schwartz M, Harrington E, et al. Treatment of ischemia due to ‘‘steal’’ by arteriovenous fistula with distal artery ligation and revascularization. J Vasc Surg 1988;7: 770-773.
18. Schanzer H, Schwartz M, Harrington E, Haimov M. Treatment of ischemia due to steal by arteriovenous fistula with distal artery ligation and revascularization. J Vasc Surg 1988; 7:770-773.
40. Teece LG. Thrombosis of the ulnar artery. Aust N Z J Surg 1949;19:156-157.
19. Conn J, Krumlovsky FA, Del Greco F. Calciphylaxis: Etiology of progressive vascular calcification and gangrene. Ann Surg 1973;177:206-210. 20. Neilsen SL, Lassen NA. Measurement of digital blood pressure after local cooling. J Appl Physiol 1977;43:907. 21. Gates KH, Tyburczy JA, Zupan T, Baur GM, Porter JM. The noninvasive quantification of digital vasospasm. Bruit 1984; 8:34-37. 22. Rosch J, Porter JM, Gralino B. Cryodynamic hand angiography in the diagnosis and management of Raynaud’s syndrome. Circulation 1977;55:807-810. 23. Wheatley MJ, Marx MV. The use of intra-arterial urokinase in the management of hand ischemia secondary to palmar and digital arterial occlusion. Ann Plast Surg 1996;37:356363.
30. Harris EJ, Taylor LM, Edwards JM, et al. Surgical treatment of distal ulnar aneurysm. Am J Surg 1990;159:527-530. 31. Koman LA, Urbaniak MD. Ulnar artery insufficiency: A guide to treatment. J Hand Surg 1981;6:16-24. 32. Vayssairat M, Debure C, Cormier JM, et al. Hypothenar hammer syndrome: Seventeen cases with long-term followup. J Vasc Surg 1987;5:838-843. 33. Mehlhoff TF, Wood MB. Ulnar artery thrombosis and the role of interposition vein grafting: Patency with microvascular technique. J Hand Surg 1991;16A:274-278. 34. Conn J, Bergan JJ, Bell JL. Hypothenar hammer syndrome: Posttraumatic digital ischemia. Surgery 1970;68:1122-1128. 35. Neilsen SL, Lassen NA. Measurement of digital blood pressure after local cooling. J Appl Physiol 1977;43:907. 36. Gates KH, Tyburczy JA, Zupan T, et al. The noninvasive quantification of digital vasospasm. Bruit 1984;8:34-37. 37. Rosch J, Porter JM, Gralino B. Cryodynamic hand angiography in the diagnosis and management of Raynaud’s syndrome. Circulation 1977;55:807-810. 38. Edwards JM, Porter JM. Update on Raynaud’s syndrome. Semin Vasc Surg 1990;3:227-235. 39. Barker NW, Hines EA. Arterial occlusion in the hands and fingers associated with repeated occupational trauma. Mayo Clin Proc 1944;19:345-349.
41. Jackson JP. Traumatic thrombosis of the ulnar artery in the palm. J Bone Joint Surg 1954;35B:438-439. 42. Goren ML. Palmar intramural thrombosis in the ulnar artery. Calif Med 1958;89:424-425. 43. Costigan DG, Riley JM, Coy FE. Thrombofibrosis of the ulnar artery in the palm. J Bone Joint Surg 1959;41A:702-704. 44. Martin AF. Ulnar artery thrombosis in the palm: A case report. Clin Orthop 1960;17:373-376. 45. Butsch JL, Janes JM. Injuries of the superficial palmar arch. J Trauma 1963;3:504-514. 46. Trevaskis AE, Marchs KM, Pennisis AM, et al. Thrombosis of the ulnar artery in the hand. Plast Reconstr Surg 1964;33: 73-76. 47. Millender LH, Nakebuff EA, Kasdon E. Aneurysms and thrombosis of the ulnar artery in the hand. Arch Surg 1973; 105:686-690.
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48. Given KS, Puckett CL, Kleinert HE. Ulnar artery thrombosis. Plast Reconstr Surg 1978;61:405-411. 49. Wagner RB, Martin AS. Peripheral atheroembolism: Confirmation of a clinical concept, with a case report and review of the literature. Surgery 1973;75:353-358. 50. Champion HR, Gill W. Arterial embolus to the upper limb. Br J Surg 1973;60:505-508. 51. James ED, Khuri NT, Fedde CW, et al. Upper limb ischemia resulting from arterial thromboembolism. Am J Surg 1979; 137:739-744. 52. Rapp JH, Reilly LM, Goldstone J, et al. Ischemia of the upper
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extremity: Significance of proximal arterial disease. Am J Surg 1986;152:122-126. 53. Bandyk DF, Thiele BL, Radke HM. Upper extremity emboli secondary to axillofemoral graft thrombosis. Arch Surg 1981;116:393-395. 54. Baker RJ, Chunprapaph B, Nyhus LM. Severe ischemia of the hand following radial artery catheterization. Surgery 1976;80:449-457. 55. Clark ET, Mass DP, Bassiouny HS, et al. True aneurysmal disease in the hand and upper extremity. Ann Vasc Surg 1991;5:276-281.
Upper Extremity Arterial Bypass Distal to the Wrist Ronald L. Dalman, MD, Palo Alto and Stanford, California
Since the initial report of Garrett et al.1 in 1965, several surgeons have published their experience with upper extremity revascularization using autogenous vein.2-7 With time and experience, these techniques have proven useful for distal bypass procedures at or below the wrist.8 Interposition vein grafting is the reconstructive method of choice following resection of posttraumatic aneurysms of the ulnar artery, a condition first described by von Rosen9 and termed the hypothenar hammer syndrome (HHS) by Conn and associates.10 Originally recognized only in machinists, carpenters, and mechanics, the HHS has more recently been described in many occupational and vocational situations, including professional and amateur athletes involved in basketball, badminton, golf, squash, and mountainbiking.11,12 Patients with the HHS are typically young and productive members of society. Prior to the wide acceptance of interposition vein grafting in the vascular, plastic, and hand surgery literature, ligation was the most commonly recommended procedure to prevent further embolization and, ultimately, digital amputation. Increased patient survival with end-stage renal disease (ESRD) is creating a larger cohort of patients with severe hand and finger ischemia.13,14 The etiologic backgrounds for these symptoms are diverse and include arterial thrombosis or steal related to dialysis access procedures,15-18 accelerated atherosclerosis, and diffuse arterial calcification and occlu-
From the Vascular Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA and Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA. Correspondence to: R.L. Dalman, MD, Vascular Surgery Section, Surgical Service (112), VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. 550
sion that occur in some cases as part of a condition termed calciphylaxis.19 Clinical presentation ranges from digital rest pain and ulceration to gangrene, and the condition occasionally necessitates digital amputation and, in severe cases, hand amputation. As is the case with posttraumatic ulnar aneurysms, the ischemic sequela of ESRD are often effectively treated by autogenous venous arterial reconstruction at or distal to the wrist. Because ischemic hand and finger symptoms are a common patient complaint, familiarity with the anatomic and technical details required for successful distal upper extremity arterial reconstructive procedures is necessary. Arterial perfusion to the hand is typically supplied by both the ulnar and radial arteries (Fig. 1). Most commonly, the ulnar artery is the largest artery crossing the wrist. Considerable overlap exists between the deep (radial) and superficial (ulnar) palmar arches. Many anomalous conditions exist, including incomplete superficial or deep arches, absence of a deep palmar branch of the ulnar artery, or superficial palmar branch of the distal radial artery resulting in a lack of collateral flow between the two arches, fusion of the deep and superficial system, and absent or diminuative ulnar or radial arteries. The frequency of these anomalies varies, but they seem to occur more commonly in symptomatic patients. Finger discoloration or pain are the predominant symptoms experienced by HHS patients. Thrombosis of ulnar artery aneurysms may lead to occlusion, but more frequently chronic digital embolization gradually occludes the proper digital arteries of the second through fifth digits. HHS patients usually present with cyanotic or pale fingers, painful or nonhealing digital ulceration. Patients with ischemic sequela of ESRD usually present with more extensive hand and digital ischemia, typically not
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Fig. 1. Posttraumatic ulnar artery aneurysm located adjacent to the hamate bone. This hand has well developed superficial and deep palmar arches, with substantial collateral flow present between the two. Symptomatic hypothenar hammer syndrome patients frequently have less well developed collateral connections between the arches.
limited to one or two individual digits. Intolerance to cold is a frequent presenting symptom in both HHS and ESRD patients. It has been our practice in such patients to rule out autoimmune or other associated disease processes. These tests include a complete blood count, erythrocyte sedimentation rate, multi-chem panel, antinuclear antibody, serum protein electrophoresis, rheumatoid factor, cold agglutinin assay, and hepatitis serology. Under appropriate clinical circumstances, hypercoaguability testing may provide important additional information. During evaluation all patients also undergo noninvasive upper extremity vascular laboratory testing including Doppler analog pulse recording; brachial, radial, and ulnar pressure determination; and digital artery closure tesing after cooling (when appropriate to the patient’s symptoms).20,21 For diagnosis of HHS, and preoperative planning prior to arterial reconstruction in any ischemic patient, selective catheter-based contrast arteriography remains our imaging standard of choice. We have no experience with alternative imaging modalities such as magnetic resonance arteriography in these patients.11 Upper extremity arteriography in these patients is technically demanding; catheter posi-
tioning in the axillary artery is required for sufficient images, and care must be taken to avoid catheter contact with the arterial wall to avoid catheter induced vasospasm. Bilateral studies are required for precise definition of baseline anatomy in most patients. Hand warming, intraarterial vasodilators, and magnification views may also be required.22 We perform all distal upper extremity arterial procedures with loupe optical magnification. General or regional anesthesia may be used. Ulnar artery aneurysms generally occur at the point where the ulnar artery passes over the hamulus (or ‘‘hook’’) of the hamate bone just distal to the pisiform bone at the wrist (Fig. 2A). Treatment goals are twofold: improve distal perfusion and prevent further embolization to the digital arteries. Following aneurysm resection, digital circulation improves in most patients, with or without extraordinary measures such as intraarterial thrombolytic therapy during or prior to surgery.23 The ulnar nerve lies immediately medial to the artery in the same plane. Both artery and nerve course medial to the flexor digitorum superficialis tendons at the wrist, and pass superficial to the flexor retinaculum. The deep branch of the ulnar artery may be involved with the aneurysmal segment or be occluded. Frequently,
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Fig. 2. A Detail of posttraumatic ulnar artery aneurysm, located distal to the pisiform bone at the wrist and distal to the deep palmar branch of the ulnar artery, but typically proximal to or just involving the common digital artery of the 5th digit. B Operative exposure via longitudinal incision directly over the palpable ulnar artery pulse. C Schematic of the arteriographic appearance of
fusiform posttraumatic ulnar aneurysms. Frequently, the artery appears irregular or serpiginous; characteristically described as a ‘‘corkscrew’’ appearance. D Repair usually involves excision of the aneurysm, with E interposition repair with reversed autogenous vein. Ideally, dorsal foot vein F provides the appropriate size match.
however, the aneurysm begins at this level and extends distally to the bifurcation of the ulnar artery into the common palmar digital artery of the 5th digit and the superficial palmar arch. Exposure is typically obtained through a longitudinal wrist incision extending to the midportion of the palm directly over the ulnar artery (Fig. 2B). Ulnar artery aneurysms are usually not large (in diameter) but rather tortuous and fibrotic, with a characteristic ‘‘corkscrew’’ appearance present on arteriography (Fig. 2C). Following aneurysm excision, the ulnar artery is reconstructed with an end to end interposition graft (Figs. 2D and 2E). Reversed vein grafts are obtained from the dorsum of the foot (Fig. 2F) when available and of adequate caliber and quality. Alternatively, basilic or cephalic arm vein conduit may be more appropriate in individual patients. Back bleeding from the distal ulnar artery, the ulnar common digital artery, the superficial palmar arch and the distal radial artery is temporarily controlled with Heifetz aneurysm clips as
needed. All anastomoses are performed with 7-0 polypropylene or 8-0 PTFE suture in continuous fashion. The adequacy of repair is confirmed by intraoperative Doppler examination. The wound is usually closed with a single layer of interrupted cutaneous 4-0 nylon suture placed in simple running or interrupted vertical mattress fashion. After operation, these patients are treated with a bulky dressing and a volar splint to immobilize the wrist. Early postoperative graft monitoring is facilitated by oximeter probe placement on an appropriate digit. The dressing and splint are changed as needed and maintained in place for 14 days. The procedure itself is usually performed as an outpatient or day procedure, with a single night stay reserved for patients with anesthetic difficulties. No special antiplatelet, anticoagulant or hemorrheologic agents are routinely used in this patient population. After immediate surgical recovery and wound healing, long-term occupational or vocational modifications are made in recognition of the
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Fig. 3. A Ulnar-ulnar vein bypass graft using forearm inflow. Note relationship to flexor digitorum superficialis muscle. B Extensive forearm involvement may require inflow from the brachial artery just below the elbow. C The bicipital aponeurosis may need to be partially divided to optimize exposure.
increased susceptibility of the ulnar artery vein graft to the same degenerative changes that prompted aneurysm formation in the first place. Failure to avoid further injury may prompt re-thrombosis or aneurysm formation in the replacement vein graft.24 As previously mentioned, patients with ESRD usually have more extensive involvement of the fingers and hand than HHS patients and more severe ischemia as documented by noninvasive laboratory studies. Ulceration is more common, as is the co-existence of contralateral symptoms and signs of hand or finger ischemia. ESRD patients may also suffer from long-standing insulin-dependent diabetes, and as such are older (average age 45 versus 34 for HHS patients),8 and have extensive atherosclerotic and/or calcific changes present throughout the arteries of the forearm and hand. In ESRD or diabetic patients, a patent distal vessel with reasonable runoff into the superficial or deep palmar arch is necessary to develop and maintain a successful bypass. Determining the appropriate location for inflow prior to bypass may also be problematic.
Inflow may be obtained from the proximal radial or ulnar artery (Fig. 3A) for distal bypass, but in ESRD patients frequently a soft and clampable arterial inflow source is found only at the level of the brachial artery just distal to the elbow (Fig. 3B). Patent but calcific palmar arteries may have backbleeding controlled by intralumenal placement and gentle inflation of [2 Fogarty™ embolectomy catheters. For bypass procedures that extend from the antecubital fossa to the wrist or palm, sections of greater or lesser saphenous veins are most appropriate. Patent ipsilateral forearm hemodialysis access fistulas or shunts may present a particular challenge in these patients, especially when alternative sites for access are not readily available. Previously placed radial-antecubital vein shunts may be present in patients with distal radial artery occlusion (Fig. 4A) or in the setting of ulnar artery occlusion with a patent distal radial artery, producing hand ‘‘steal’’ symptoms proportionate to the fraction of radial artery flow diverted through the shunt. Retrograde radial artery flow distal to the radial artery
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Fig. 4. A Ischemic hand with functional ipsilateral radial-cephalic arteriovenous dialysis shunt. Both radial and ulnar occlusions are present, but flow continues through the radial artery to the level of the shunt B. Ideally, hand revascularization may be accomplished without sacrifice of the functional access site. C Revascularization based on proximal radial artery inflow, with inset showing level of incision and proximal anastomosis of the ultimate radial-radial bypass.
anastomosis is common.25,26 When associated with ischemic symptoms or signs, especially in the setting of forearm arterial occlusive disease, radial steal becomes pathologic27 and may be easily confirmed by duplex scanning in the noninvasive vascular laboratory. In the case outlined in Figure 4A, radial and ulnar artery occlusions are present, resulting in severe hand ischemia. In addition to the typical symptoms outlined above, these patients may also experience ischemic monomelic neuropathy, especially in the setting of pre-existing diabetic neuropathy. Ischemic monomelic neuropathy causes severe hand and forearm pain, paresthesias, and hypesthesia, and may not be reversible following revascularization.28 If ischemic symptoms co-exist with retrograde distal radial artery flow, the shunt may be removed as a simple definitive treatment. However, if distal radial and ulnar artery occlusions are also present, hand revascularization may be required regardless of the ultimate disposition of the shunt.29 Under these circumstances, an autogenous vein graft from the proximal radial or brachial artery to the distal
radial artery in the anatomic snuffbox (formed by the extensor pollicis brevis and longis tendons on the lateral aspect of the wrist) may suffice to relieve ischemia in the hand while maintaining viable ipsilateral hemodialysis access (Fig. 5). Bypass to the distal radial artery avoids re-operation near the inflow anastomosis of the dialysis access shunt and presumably minimizes the chance of bypass graft injury from hemodialysis cannulation. When the distal ulnar artery or superficial palmar arch are present and patent, they may represent more suitable bypass targets under these circumstances.
CONCLUSION Surgically correctable, noniatrogenic arterial lesions of the hand or forearm are an uncommon cause of chronic hand ischemia. At least 170 cases of ulnar artery aneurysm have been reported in the Englishlanguage literature since 1944.30-48 Other causes of hand and finger ischemia are encountered more frequently and include embolization from a car-
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Fig. 5. A, B Relationship of radial artery to the extensor aponeurosis and tendons which comprise the anatomic snuffbox on the dorsal surface of the arm. C Radial-radial reversed autogenous vein graft, with proximal anastomosis detailed in Figure 4C, and distal anastomosis within the anatomic snuffbox. D Completed revascularization, with inline pulsatile arterial flow restored to the deep palmar arch via radial-radial autogenous vein bypass grafting and continued patency of pre-existing dialysis access shunt.
diac49-52 or proximal noncardiac arterial source,53,54 atherosclerotic occlusive disease of the arteries proximal to the wrist without distal embolization,1-7 and brachial and radial occlusion after cannulation.1-7,19 Despite the relatively rare incidence of symptomatic arterial occlusive at or distal to the wrist, a growing number of these patients may be candidates for arterial bypass or resection and interposition. Good long-term symptomatic improvement and vein graft patency rates have now been reported by several groups with the use of the interposition vein grafting techniques described in this review.30,33,55 In HHS patients, interposition vein grafting has the benefit of preventing further embolization and in maintaining distal perfusion. In ESRD patients, fistula or shunt patency may be preserved while distal bypass grafting markedly improve finger or hand perfusion. Surgery for the HHS should be reserved for symptomatic patients; patients with asymptomatic thrombosis of ulnar artery aneurysms should not undergo resection and revascularization based
on the available data at this time. The overall natural history of asymptomatic ulnar aneurysms remains unknown. Patients with ESRD and/or diabetes should also be treated on a symptomatic basis. The role for long-term graft surveillance remains unknown at this time following treatment of either HHS or ESRD related ischemia. The distal nature of these bypasses does not appear to compromise performance or outcome, and we and others are choosing them with greater frequency and confidence.
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