Low-dose fibrinolytic therapy in hand ischemia

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

Distal arm and hand ischemia from vessel thrombosis or embolism remains a difficult clinical challenge. The causes of ischemia are variable and include connective tissue disease, embolism, atherosclerosis, and iatrogenic etiology. Although reports are limited, treatment with catheter-directed thrombolysis has favorable results in cases of acute thrombosis, with most patients (80%) demonstrating improvement. Digital amputation rates are less than 10% and the hand is often salvaged. Bleeding and access-site complications remain prevalent in patients undergoing intra-arterial thrombolysis. This review discusses etiology, treatment approaches, outcomes, and complications when thrombolytic therapy is used for distal arm and hand ischemia.

Acute arterial occlusions of the small vessels of the hand and forearm: treatment with regional urokinase therapy

PURPOSE

Arterial occlusions of the small vessels of the forearm and hand may have the same consequences as arterial occlusions in the distal lower extremity. There is limited reported experience with the regional thrombolytic therapy in this setting. The authors reviewed their experience with thrombolytic therapy in acute and subacute arterial occlusions of the distal upper extremity to further clarify its role.

MATERIALS AND METHODS

Twelve patients with acute or subacute arterial occlusions of the forearm and hand who had ischemic digits and were treated with regional urokinase infusion were identified retrospectively. Their medical and radiology records were reviewed.

RESULTS

All 12 patients demonstrated angiographic improvement and 11 patients demonstrated clinical improvement after treatment. Tissue necrosis in four patients led to partial amputation of one digit in two patients and three digits in two patients. Three of these patients had category III ischemia at presentation. The level of resulting amputation was altered in all but one patient. Vasospasm was noted frequently but responded to vasodilators. No significant complications occurred.

CONCLUSIONS

When therapeutic alternatives are limited to anticoagulation and expectant amputation, regional urokinase infusion can optimize distal runoff, obviate or improve the options for distal surgical bypass, and limit tissue loss.

Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis

Fifty consecutive patients with acute and chronic ischemia of the hand were investigated by Allen testing, Doppler ultrasound, digital plethysmography, and angiography over a 4-year period. The pathophysiologic mechanism responsible for the ischemia was determined to be emboli in 6%, vasospasm in 10%, thrombosis or "sludging" in 28%, occlusive disease in 26%, and occlusive disease associated with either vasospasm or external compression in 30%. Ten patients required emergency medical treatment with intraarterial streptokinase, intravenous heparin, or dextran 40 and continuous stellate ganglion blocks, and three patients required emergency microsurgical revascularization because of radial artery thrombosis. Patients with chronic ischemia of the hand were maintained on nifedipine, 30 to 60 mg daily, and pentoxifylline, 1200 mg daily. Seven patients underwent digital sympathectomy and 14 patients underwent microsurgical revascularization as prophylactic procedures for chronic digital ischemia. Amputations were required in 18 patients because of end-stage gangrene. Long-term follow-up revealed a 20% incidence of recurrent digital ulcerations. There have been six deaths during follow-up, five of them due to myocardial infarction; this reflects the underlying systemic arteriopathy in many of these patients.

Extensive thromboembolic disease of the hand and forearm: treatment with thrombolytic therapy

Six patients with extensive hand and forearm thromboembolic disease were treated by means of intraarterial infusion of urokinase, with good clinical results. Four significant complications occurred, including a possible stroke. Embolization of pericatheter thrombus was a possible etiologic factor in this case. Antegrade brachial artery puncture should be used in the setting of prolonged upper extremity thrombolytic therapy to avoid the cerebral vasculature. Thrombolysis is an effective technique for tissue salvage in cases of inoperable hand thrombosis.

Selective heparinization of venous anastomosis in latissimus dorsi free flaps to cover lower-extremity soft-tissue defects

Two groups of consecutive patients treated with latissimus dorsi free myocutaneous flaps to cover lower-extremity soft-tissue defects were compared for postoperative vascular occlusion. In the first group of 13 patients (group I), there were five (38%) venous occlusions and no arterial occlusions. The second group of 15 patients (group II) was treated with selective heparinization of each venous anastomosis via a 0.35" catheter sutured into the serratus branch of the donor vein. In this group one patient suffered an arterial occlusion, but no patient suffered a venous occlusion. Statistical analysis using the Fisher exact probabilities test showed a significant decrease in vascular occlusion rate in group II, proving that selective heparinization had a beneficial effect on the venous patency rate.

Accelerated thrombolysis and angioplasty for hand ischemia in Buerger's disease

A patient with severe hand ischemia due to Buerger's disease was treated by a rapidly effective modification of percutaneous catheterization. Accelerated mechanical and pharmacologic thrombolysis of an occluded palmar arch with 200,000 U urokinase and subsequent small vessel angioplasty abolished pain and restored digital perfusion within 40 min.