Total Percutaneous Revascularization of the Hand to Treat Refractory Digital Ischemia in Advanced Systemic Sclerosis

Unveiling the Enigma: Idiopathic Digital Infarction-A Case Report and Literature Review

Idiopathic digital infarction (IDI), a rare subset of digital infarction, is characterized by ischemic changes in the absence of identifiable underlying etiology. We present the first documented case of IDI in a 47-year-old female with insignificant medical history. Clinical evaluation revealed bluish discoloration of the left lateral three fingers. Negative findings on autoimmune serologies, echocardiogram, and coagulation profiles excluded common causes, such as vasculitis, cardiac embolism, and hypercoagulable states. Imaging studies demonstrated ischemic changes in the left cerebellar hemisphere and proximal left subclavian artery, which supported the diagnosis of acute infarction. The patient was managed conservatively and was discharged. This case underscores the diagnostic complexities of IDI and highlights the importance of thorough evaluation and management.

Digital ulcers associated with scleroderma: A major unmet medical need

Scleroderma or systemic sclerosis (SSc)-associated digital ischaemic complications, such as digital ulcers (SSc-DUs), appear relatively early during the disease course and are a major burden with substantial deterioration of quality of life. Expert rheumatologist and wound specialists have defined a DU; however, international application of the definition is still disorganised. Appearance of SSc-DUs is secondary to the onset of Raynaud's phenomenon and as a consequence, recommended first-line of treatment mainly includes vasodilators; however, many DUs are refractory to this treatment. Despite important practical issues, such as a lack of well-characterised SSc-wound healing animal model, significant efforts are needed to mechanistically understand the pathogenesis of SSc-DUs for developing clinically targetable disease modifying therapies.

Percutaneous revascularization for the treatment of refractory digital ischemia in systemic sclerosis

Objective

The objective of this study is to explore the role of adjunctive percutaneous revascularization of the hand in the management of patients with systemic sclerosis-associated refractory digital ischemia.

Methods

We present our initial experience of using percutaneous upper extremity interventions to treat patients with systemic sclerosis and symptomatic Raynaud's phenomenon who presented with either refractory digital ischemia or non-healing ulcers. We discuss patient characteristics, procedural findings, and short-term clinical outcomes of these interventions.

Results

We performed 14 interventions in 6 patients with non-healing digital ulcers or refractory ischemia secondary to systemic sclerosis. Angioplasty was performed at or below the wrist in conjunction with intravenous prostaglandin therapy, started prior to or immediately after the revascularization procedure. All patients experienced symptomatic relief and demonstrated accelerated wound healing. Two patients required an additional procedure to treat recurrent ischemia (without new ulceration) in the treated digit. Three of the patients underwent multiple procedures during the study period to treat new ischemic lesions or Raynaud's phenomenon symptoms, highlighting the progressive nature of the vascular occlusions in systemic sclerosis. There were no adverse events related to the interventions.

Conclusions

Our retrospective analysis suggests that percutaneous revascularization in combination with vasodilator therapy in systemic sclerosis-associated digital ischemia is safe and can facilitate the healing of long-standing ulcers. Its role in the management of refractory digital ischemia in patients with systemic sclerosis should be explored further.