The role of thrombolytics in acute and chronic occlusion of the hand

Distal periarterial sympathectomy surgery for chronic digital ischemia: A systematic review of the literature

Objective

This study assesses the efficacy of distal periarterial sympathectomy in treating chronic digital ischemia by evaluating clinical outcomes of surgery.

Methods

A systematic literature review of distal sympathectomy for chronic digital ischemia was conducted. Data extracted included study design, patient statistics, aetiology, follow-up duration, sympathectomy level, and surgical outcomes.

Results

21 studies were analysed, containing a total of 337 patients, 324 hands, and 398 digits. Patient age ranged from 23.2 to 56.6 years. Causes of ischemia included Scleroderma, Raynaud's disease, atherosclerosis/Buerger's disease, systemic lupus erythematosus/discoid lupus, undifferentiated rheumatic disorder/mixed connective tissue disease, CREST syndrome, trauma and unknown diagnoses. Common digital artery sympathectomy was mostly performed. Follow-up spanned 12-120 months.

Outcomes

Distal sympathectomy led to reduced pain in 94.7 % patients. Complete resolution of ulceration was seen in 73 % patients. Subsequent amputation was required in 28 % patients. Other complications were reported in 24.1 % patients.

Conclusions

This study indicates that distal periarterial sympathectomy may effectively treat chronic digital ischemia, offering pain relief and resolution of digital ulceration. However, risks of complications and amputation persist. Further research is required to inform patient selection and establish the optimal technique and extent of distal sympathectomy surgery, before it can be considered a valid treatment option.

Successful percutaneous management of hypothenar hammer syndrome with thrombosuction and catheter-directed intra-arterial thrombolysis

Hypothenar hammer syndrome (HHS) is a rare vascular disorder leading to ulnar artery thrombosis or aneurysm and causing acute or chronic limb ischemia. The optimal approaches to managing this condition lack a definitive consensus and are essentially empirical, typically necessitating conservative methods for symptomatic relief, with surgical intervention reserved for cases for which conservative measures prove inadequate or when acute limb ischemia ensues. Limited data are available on percutaneous management for this condition. We present the case of a 36-year-old male powerlifter who developed acute digital ischemia due to HHS in the left hand that was managed successfully through an innovative approach using antegrade left brachial artery access and combining percutaneous thrombosuction and intra-arterial thrombolysis. This comprehensive approach resulted in restoration of blood flow and resolution of acute limb ischemia. The patient was subsequently prescribed short-term anticoagulation therapy and remained symptom free at 3 months of follow-up. This innovative strategy challenges traditional surgical approaches in HHS management, underscoring the importance of using minimally invasive techniques as a promising alternative and highlighting potential avenues for further research.

Catheter-Directed Thrombolysis for Acute Digit Ischemia in the Setting of Heterozygous Factor V Leiden Mutation: A Case Report and Review of Literature

CASE

We are reporting the successful treatment of a patient with a heterozygous factor V Leiden mutation who presented with spontaneous thrombotic ischemia of ring and small fingers. Microcatheter-directed administration of thrombolytics at the level of common and proper digital arteries resulted in the salvage of the ring finger to the level of the distal tuft and the entirety of the small finger.

CONCLUSION

Heterozygous factor V Leiden mutation is an extremely unusual etiology for thrombotic digital ischemia. This case report emphasizes the importance of correct diagnosis, timely intervention, and thrombolytic therapy using microcatheters to optimize digital rescue.

Endovascular Thrombolysis in Hypothenar Hammer Syndrome: A Systematic Review

Objectives: Hypothenar hammer syndrome (HHS) is a rare vascular disease caused by blunt trauma of the hypothenar region. The optimal therapeutic strategy remains debatably since no large comparative studies are available yet. We want to evaluate the effectiveness of intra-arterial thrombolysis on angiographic and clinical outcome parameters in patients with HHS by performing a systematic review of the existing literature.

Methods: A literature search of PUBMED/MEDLINE and SCIENCE DIRECT databases was performed up to May 2021.

Results: In total, 16 manuscripts with 43 patients were included in the systematic review. Intra-arterial thrombolysis led to angiographic improvement in 29 patients (67.4%) and to clinical improvement in 34 patients (79.1%). Deterioration of arterial perfusion or clinical symptoms after thrombolysis were absent. Post-interventional complications were reported in only one patient (2.3%) without any bleeding complication. Logistic regression analyses demonstrated that a combined administration of fibrinolytics and heparin was associated with a significantly improved arterial patency [OR 12.57 (95% CI 2.48–97.8), p = 0.005] without significant amelioration of clinical symptoms [OR 3.20 (95% CI 0.6–18.9), p = 0.172]. The use of rt-PA compared to other fibrinolytics and a prolonged thrombolysis duration of more than 24 h did not show statistically significant effects. Intra-arterial thrombolysis was significantly less effective in patients who had undergone thrombolysis with a delay of more than 30 days regarding clinical improvement [OR 0.07 (95% CI 0.00–0.54), p = 0.024].

Conclusions: Intra-arterial thrombolysis with a combination of fibrinolytics and heparin is an effective and safe therapeutic option in patients with acute HHS.

Thrombolysis Enhancing by Magnetic Manipulation of Fe₃O₄ Nanoparticles

In this paper, an effective method of accelerating urokinase-administrated thrombolysis through a rotating magnetic field (RMF) of guided magnetic nanoparticles (NPs) in the presence of low-dose urokinase is proposed. The dispersed Fe₃O₄ NPs mixed with urokinase were injected into microfluidic channels occluded by thrombus prepared in vitro. These magnetic NPs aggregated into elongated clusters under a static magnetic field, and were then driven by the RMF. The rotation of Fe₃O₄ aggregates produced a vortex to enhance the diffusion of urokinase to the surface of the thrombus and accelerate its dissolution. A theoretical model based on convective diffusion was constructed to describe the thrombolysis mechanism. The thrombus lysis speed was determined according to the change of the thrombus dissolution length with time in the microfluidic channel. The experimental results showed that the thrombolysis speed with rotating magnetic NPs is significantly increased by nearly two times compared with using the same dose of pure urokinase. This means that the magnetically-controlled NPs approach provides a feasible way to achieve a high thrombolytic rate with low-dose urokinase in use.

A case of intra-arterial thrombolysis with alteplase in a patient with hypothenar hammer syndrome but without underlying aneurysm

Hypothenar hammer syndrome is a cause of symptomatic ischemia of the hand secondary to the formation of aneurysm or thrombosis of the ulnar artery in the setting of a complete or incomplete palmar arch. Acute occlusive thrombus or embolus of the hand represents a complex problem that often may require immediate surgical intervention. We report a case of acute unilateral arterial hand ischemia requiring catheter-directed thrombolysis with Alteplase therapy in a patient with acute occlusive arterial thrombosis of the left ulnar artery. A catheter-directed thrombolytic regimen consisted of Alteplase 1 mg/h for 24 h, and heparin was infused through the sheath side arm at a rate of 500 units per hour for resolution of the thrombus and improvement in symptoms. A former truck driver presented with worsening pain and subsequent development of significant cyanosis with early gangrenous changes of the left second and third fingertips. He had significant callous of the hypothenar eminence and reported that his left hand was not only his “driving” hand but also a cane has been used in his left hand to ambulate. Initial angiogram revealed only ulnar artery occlusion at the wrist with reconstitution just distal to the hypothenar eminence. After 24 h of the initiation of thrombolysis, repeat angiography revealed resolution with a widely patent ulnar artery. His symptoms and the color of his digits immediately improved, and within a few months, his hand had normalized. The patient had no clinical sequelae of thrombolytic therapy. Catheter-directed thrombolytic therapy in situations of acute occlusive thrombus of the hand may provide a therapeutic option for patients with suspected hypothenar hammer syndrome. However, thrombolytic therapy carries risk of significant hemorrhagic complications. Before initiating therapy, careful judgment about the possibility for bleeding risk is required. This provides for a minimally invasive alternative to open surgical revascularization especially in the absence of underlying correctable anatomic defect such as aneurysm.

Acute Ischemia of the Upper Extremity

Ischemia of the upper extremity is uncommon but can be seen with open or closed trauma. Those dealing with traumatic injury of the upper extremity should be conversant with techniques of vascular surgery and microsurgery to address these injuries when they occur. Closed injury can occur as well, and at times these are best managed nonoperatively. This article discusses the management of both in the acute setting.

Nonoperative Management of Acute Upper Limb Ischemia

BACKGROUND

Acute upper limb ischemia (AULI) is an uncommon emergency warranting immediate evaluation and treatment. The role of nonsurgical therapies including endovascular techniques, thrombolytics, and anticoagulation remains undefined. The authors systematically reviewed the current literature on the nonsurgical treatment of acute ischemia of the upper extremity.

METHODS

A PubMed and Embase search was conducted, and articles were screened using predetermined criteria. Data collected included patient demographics, cause of upper limb ischemia, type of nonsurgical treatment used, treatment outcomes, and complications. Patients were divided into 4 treatment groups: catheter embolectomy, catheter-directed thrombolysis, endovascular stenting, and anticoagulation/medical therapy alone.

RESULTS

Twenty-three retrospective studies met the search criteria. Of 1326 reported occlusions, 92% (1221) were attributed to thromboembolic disease. The second most common cause was iatrogenic (1.5%). Overall limb salvage rates were excellent with catheter embolectomy (862 of 882 cases, 97.7%) and catheter-directed thrombolysis (110 of 114 cases, 96.5%). Limb salvage rates were also high with anticoagulation/medical therapy (158 of 165 cases, 95.8%), but poor functional outcomes were more often reported.

CONCLUSIONS

High-quality evidence to guide the nonsurgical treatment of AULI is lacking. Retrospective studies support the utility of catheter-based embolectomy and thrombolysis for distal ischemia. Whether a surgical or nonsurgical approach is taken, anticoagulation therapy remains a mainstay of both treatment and prevention of AULI. Because AULI patients often have underlying cardiac and/or systemic disease, a multidisciplinary approach is essential to minimize complications and prevent future occurrences.

Acute Arterial Thrombosis of the Hand

Arterial thrombosis of the hand occurs infrequently but may result in considerable morbidity and compromise of hand function. The hand surgeon may be called upon to direct management in cases of acute arterial thrombosis of the hand and should have an understanding of the available diagnostic tools and treatment modalities. This article discusses the vascular anatomy of the hand and clinical manifestations of arterial thrombosis. Differences between isolated thrombosis and diffuse intravascular injury are detailed, and treatment options for these conditions are described. Appropriate care often requires coordination with interventional radiologists or vascular surgeons. Outcomes after treatment of arterial thrombosis of the hand are variable, and prognosis may be related to whether isolated thrombosis or diffuse intravascular injury is present.