Composite in situ vein bypass for upper extremity revascularization

Palmar bypass for digital ischemia

Although vein bypass grafting in lower extremity and heart tissue ischemia is well documented, little information exists with regard to its selective use for digital ischemia in the hand. Resection and ligation and interposition grafting are most commonly performed to treat digital ischemia and have received the most attention in the literature. We report on 3 cases of successful vein bypass grafting from the distal forearm to the palmar arch or common digital artery as a technique to reverse current and prevent further digital tip ischemia or necrosis.

Arterialization of the Venous System of the Hand

BACKGROUND

The treatment of hand ischemia can be very challenging. In cases in which there are no reconstructible arterial lesions, treatment options are limited. Arterialization of the venous system of the hand is a straightforward surgical procedure that provides arterial blood to the distal soft tissues of an ischemic hand.

METHODS

The author conducted a retrospective review of the history, indications, technique, and results of this technique as applied to the treatment of five hands in three patients.

RESULTS

For each of these patients, the treatment included an anastomosis from the distal radial or ulnar artery to a dorsal hand vein. Blood flow was directed distally by ligating venous side branches. Valvulotomies were performed as needed to the base of the digits on the dorsum of the hand. This approach resulted in excellent pain relief in all treated hands and healing of digital wounds.

CONCLUSION

This relatively straightforward salvage procedure provides arterialized blood to ischemic digits, resulting in wound healing and significant reduction in pain.

Brachial artery reconstruction for occlusive disease: a 12-year experience

OBJECTIVE

Symptomatic arterial disease of the upper extremity is an uncommon problem. In this study, we evaluate our results with brachial artery reconstruction in patients who present with symptomatic atherosclerotic occlusive disease and compare this cohort's demographics with a similar group with lower extremity ischemia.

METHODS

From 1986 to 1998, all patients presenting for upper extremity revascularization with chronic ischemia were prospectively entered into a vascular registry. Demographics, indications, outcomes, and patency were recorded. Patients presenting with embolus, pseudoaneurysm, or trauma were excluded. The Fisher exact and Student t tests were used to assess significance.

RESULTS

Fifty-one (83%) bypass grafts were performed with autogenous conduit and the remainder with polytetrafluoroethylene. Indications included 18 (30%) patients with exertional arm pain, 35 (57%) with rest pain, and 8 (13%) with tissue loss. Twenty-five (45%) patients were male, 8 (14%) had diabetes, and 30 (54%) were smokers. The mean age was 58 years (range, 33-93). The operative mortality rate was 1.8%, and follow-up ranged from 1 to 140 months. Eight occlusions were identified, with six occurring early. Five of these were in women with a smoking history. Only one of the 26 reconstructions that did not cross a joint occluded, whereas bypass grafts that did cross a joint occluded more frequently. No other major complications were recognized.

CONCLUSION

Arm revascularization for ischemia can be performed with reasonable mortality and morbidity rates. These patients may represent a different subgroup of atherosclerotic disease than those with lower extremity involvement: they are more commonly women and smokers and less likely to be diabetic.

In situ and composite in situ vein bypass for upper extremity ischaemia

The in situ saphenous vein bypass for lower limb revascularisation is well established. For upper extremity ischaemia necessitating bypass this special technique offers the same advantages. From 1987 to 1991 five patients underwent cephalic and basilic vein in situ bypass for critical ischaemia of the upper extremity. Underlying disease was a thoracic outlet syndrome (two cases), radiation injury (one case) and a chronic atherosclerotic lesion (two cases). One graft failed because of a critical outflow situation. The most important advantage of the in situ technique for revascularisation of the upper extremity seems to be minimal endothelial damage and the better compliance of the in situ vein to the extensive movements of the joints.