Arterialization of the Venous System for Salvage of Critical Hand Ischemia

Purpose

Limited salvage options exist for critical hand ischemia secondary to distal arterial disease, which are not amendable to bypass.  Arterialization of the venous system in the upper extremity has recently regained attention, however only scattered cases are reported in the literature.  Our study aims to determine the outcome of venous arterialization to assess its clinical feasibility in limb salvage.

Method

All patients who underwent venous arterialization for acute and chronic hand ischemia at a single institution were retrospectively reviewed.  Indications, operative details, preoperative and postoperative findings as well as requirement of further amputation were studied. Prospective clinical, doppler, oxygen saturation and duplex ultrasound evaluations were performed. 

Results

A total of 8 hand arterializations were performed in 6 patients with mean age of 55 (range 33 to 75) who presented with severe ischemic pain of the hand and clinical evidence of arterial vascular insufficiency.  There were 2 hands with acute ischemia (symptoms under 1 week) and 6 with chronic symptoms.  Etiology includes atherosclerosis (4), Raynauds disease (2), distal embolic arterial occlusion secondary to IV drug use (1), and distal arterial aneurysm and diffuse narrowing due to Buerger’s disease (1).  All cases were distal arterial occlusions not amendable to bypass that were confirmed on pre-operative imaging.  The cephalic vein was placed end-to-side into the radial artery in the vicinity of the wrist in all 8 cases.  During a mean follow-up period of 6.8 months (range 2 to 17 months), all patients exhibited immediate pain reduction, and demonstrated ischemic ulcer healing, improved range of motion and/or sensation.  All arterialized hands survived. Two patients presenting with acute ischemia required fingertip amputations for ischemic changes that were irreversible despite venous arterialization. Six hands were evaluated prospectively. All had arterial doppler and duplex ultrasound signals at anastomsis, dorsal veins and at least one digital arteries to the pulp, with oxygen saturation >94% to all fingers.

Conclusion

Our study is the largest series to demonstrate that venous arterialization may be a valuable salvage option in the setting of acute and chronic arterial ischemia of the hand when traditional forms of revascularization are not feasible.