Percutaneous transluminal angioplasty for treatment of critical hand ischemia with a novel endovascular approach: “The radial to ulnar artery loop technique”
Article Outline
A 44-year-old patient with type I diabetes with critical upper limb ischemia of the left hand was referred to our department with ischemic tissue loss and rest pain. After unsuccessful use of the endovascular antegrade approach, retrograde revascularization with percutaneous transluminal angioplasty (PTA) of the ulnar artery and the Palmar arch through the radial artery was successfully performed (the radial to ulnar artery loop technique). Relief of the patient's symptoms was immediate and ischemic lesions were healed at 6-month follow-up. This technique, which has been used for the first time in critical upper limb ischemia, may significantly increase the success rate of percutaneous angioplasty, especially when antegrade recanalization fails.
Occlusive disease of the infrabrachial arteries is rare even in patients with diabetes and chronic renal failure.1 These patients usually experience pain and tissue necrosis, generally starting at the fingers, and require urgent revascularization. Only a few cases have been reported regarding bypass grafting and the use of percutaneous angioplasty in forearm arteries.1, 2 Minimally invasive techniques, such as angioplasty with or without stent placement and thrombolysis, are being increasingly used for symptomatic upper limb ischemia.
In this case, we present a patient who was successfully treated by endovascular means with a novel technique: the radial to ulnar artery loop technique that, to the best of our knowledge, is being described for the first time.
Case report
A 44-year-old patient with type I diabetes under peritoneal dialysis since 2005 was referred to our department with pain at rest and digital ulceration of the fourth finger of the left hand over the last 3 weeks. The patient was affected by multiple comorbidities (retinopathy, peripheral vascular disease – femoral to popliteal artery bypass) but had no history of cardiac arrhythmias and no previous forearm – wrist trauma and/or surgery. No signs of an active vascular inflammatory illness such as fever and/or elevation of the erythrocyte sedimentation rate were present.
The patient had rest pain and was assuming opioids for pain control. Physical examination showed necrotic tissue at the tip of the fourth digit with no ulnar but with normal brachial and radial pulse. A computed tomography (CT) angiogram showed normal patency of the left subclavian artery and an echo-color Doppler showed a patent brachial and radial artery, with proximal occlusion of the ulnar artery extending to the wrist.
Preliminary arteriography, via a left antegrade transbrachial approach (4F catheter, 10-cm long introducer sheath, Terumo, Japan), was performed and confirmed a patent radial and interosseous artery with a proximal total occlusion of the ulnar artery up to the level of the wrist (Fig 1). The superficial and deep Palmar arch remained patent and was fed by the radial artery. Heparin was given intra-arterially in order to maintain an activated clotting time >250 seconds. An antegrade revascularization was initially attempted using three different 0.014-inch guidewires (“Choice PT” and “PT Graphix Super Support” initially – Boston Scientific, Natick, Mass, and afterwards a “Pilot 200” – Abbott Vascular, Abbott Park, Ill) with a balloon angioplasty catheter (2 mm × 80 mm × 120 cm, “Amphirion Deep”, Invatec, Brescia, Italy) that was used also as a support catheter. Even though three different guidewires were chosen, it was impossible to cross the totally occluded vessel.
Fig 1.
Digital subtraction angiography (DSA) of the hand shows a patent radial artery with occlusion of the ulnar artery up to the level of the wrist.
After re-evaluating the preliminary angiography, the radial artery and the Palmar arch (Fig 2) were selectively catheterized using the same balloon mounted on the 0.014-inch guidewire (“Pilot 200”, Abbott Vascular). Once the guidewire was advanced through the superficial Palmar arch, the distal part of the occluded ulnar artery was successfully engaged; then the guidewire together with the balloon was advanced proximally to the elbow and retrograde recanalization with balloon angioplasty was performed. The final angiogram showed a complete recanalization of ulnar artery with direct flow to the deep Palmar arch and better visualization of digital arteries (Fig 3).
Fig 2.
The 0.0014-in guidewire was advanced to the radial artery and passed through the superficial Palmar arch together with the balloon catheter; then the distal part of the occluded ulnar artery was engaged and retrograde recanalization with balloon angioplasty of the Palmar arch and the ulnar artery was successfully performed with a 2 mm × 80 mm balloon catheter (“Amphirion Deep”, Invatec, Brescia, Italy). Note that the normal anatomy of the Palmar arch has been maintained during balloon dilatation.
Fig 3.
The final angiographic result shows recanalization of the ulnar artery and direct flow to the deep Palmar arch with better visualization of digital arteries.
The postoperative period was characterized by no complications with an immediate decrease in pain intensity and the patient was discharged the day after the procedure. At 30 days follow-up, the ulnar artery pulse was still palpable, the wound began to heal, and the patient confirmed that he did not feel any pain. At 6 months follow-up, the patient was still doing well, had no pain, and complete healing of the lesion was observed.
Discussion
Critical upper limb ischemia is most frequently caused by thromboembolic disease and acute traumatic or iatrogenic arterial injury. Connective tissue disorders and several arteritis may also present a rare cause of upper extremity occlusive disease. It is well known that dialysis patients show a very high prevalence of cardiovascular complications, as they are affected by abnormal and accelerated vascular calcifications. Patients generally experience pain, discoloration, ulcerations, tissue necrosis, and/or gangrene of the fingers (generally starting at the fingertips). These symptoms commonly lead to disability but total limb loss is rare.3
Revascularization is most beneficial for patients with lifestyle-limiting symptoms and necessary when acute or chronic limb ischemia with rest pain or nonhealing ulcers are present. Current conservative therapy consists of risk-factor modification and antiplatelet somministration, even if traditional surgery still continues to play an important role.4
In this particular case, even if a normal patented radial artery was present, it was not sufficient to support complete perfusion of the hand and digital ulceration with diffuse pain at rest of the forearm and the wrist led us to consider endovascular recanalization as an alternative to traditional surgery. Our own experience, coming from lower limb ischemia and below the knee interventions combined with the critical condition of the patient, encouraged us to take the eventual risk (dissection/occlusion of the radial artery and/or the Palmar arch) and perform the procedure.
In our opinion, the retrograde revascularization of an occluded artery of the forearm may be considered when antegrade recanalization has no success and when there is at least one patent artery feeding a normal Palmar arch. Additionally, in order to perform this procedure, it is necessary to use very low profile balloons, preferably 80 to 150-mm long and extra stiff hydrophilic 0.014-inch guidewires.
Conclusions
The development of newly dedicated materials (low profile long balloons, extra support guidewires, etc) and the experience that has been acquired by performing upper2, 5 and lower limb endovascular procedures (such as the “pedal-plantar loop technique”)6 make percutaneous therapy a valid alternative for the treatment of symptomatic chronic upper limb ischemia.
This technique may improve results of endovascular therapy, reduce failure rates, and may offer a valid alternative in patients with severe upper limb ischemia, especially when antegrade recanalization is impossible.
References
- Upper extremity bypass grafting for limb salvage in end-stage renal failure. J Vasc Surg. 2003;38:1313–1315
- . Chronic hand ischemia treated with radial artery balloon angioplasty: case report. J Hand Surg Am. 2008;33:551–554
- . Obliterative arterial disease of the upper extremity. Arch Surg. 1981;116:1593–1596
- . Vascular disorders of the upper extremity. Orthopaedic Journal. 1998;11:52–58
- . Successful percutaneous angioplasty and stenting of the radial artery in a patient with chronic upper extremity ischemia and digital gangrene. J Endovasc Ther. 2007;14:426–428
- . Pedal-plantar loop technique for a challenging below-the-knee chronic total occlusion: a novel approach to percutaneous revascularization in critical lower limb ischemia. J Invasive Cardiol. 2007;19:E34–E37
Competition of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.
PII: S0741-5214(09)01478-5
doi:10.1016/j.jvs.2009.07.067
© 2010 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
