Arterialization of the venous system for treatment oflimb threateninghand ischemia
Mary Kala Zorn1, Malachi Sheahan2, Gleb Medvedeb1, Nicolas Zea2
1Tulane Medical Center, New Orleans, LA;2LSU, New Orleans, LA
INTRODUCTION: Chronic upper limb ischemia is a rare disease that is typically difficult to treat due to underlying comorbidities. Although arterial bypass is the procedure of choice for revascularization, often these patients do not have adequate distal outflow targets for reconstruction. We present a patient with upper extremity occlusion of the distal radial artery of unknown etiology who underwent arterialization of the venous system as a salvage procedure.
METHODS: A 68-year-old male presented with a two-week history of worsening pain in the first three digits of his right hand. On exam, the patient had dry gangrene of the distal tip of his second digit, progressive mottling of his first and third digits, and debilitating tenderness and pain. Catheter angiography demonstrated distal occlusion of the radial artery, a patent ulnar artery, and incomplete filling of the palmar arch with minimal flow to the first and second digits. An adequate outflow target could not be identified. The decision was made to anastomose a dorsal branch of the cephalic vein (dissection confirmed that the vein traveled towards the thumb and the index) to the radial artery at the level of the wrist. Completion angiogram verified antegrade blood flow via the dorsal venous network to the first three digits, and there was a palpable pulse over the dorsal aspect of the hand with biphasic doppler signals in the web spaces.
RESULTS: Post-operatively, the ischemic region of the second digit demarcated and he underwent distal interphalangeal amputation one month later with complete healing. The patientís pain was completely ameliorated, and he had no further evidence of ischemia in his digits.
CONCLUSIONS: Arterialization of the venous system has been described in both upper and lower extremity cases where chronic ischemia is not amenable to arterial revascularization secondary to poor outflow vessels or diffuse hypoperfusion. Our case demonstrates that reversal of venous flow can lead to improved wound healing, decreased pain, and prevention of further ischemia. Since there is a paucity of data regarding this technique, further investigation is warranted to validate its effectiveness in upper extremity limb salvage.
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