Use of Arterial Grafts in Hypothenar Hammer Syndrome: Application of Perforator Flap Anatomy

Reconstruction of the ulnar artery in Guyon's canal with an arterial graft: Anatomical study

Ulnar artery thrombosis in Guyon's canal can lead to vascular insufficiency in the fingers. The recommended treatment is resection and reconstruction of the pathological area. A bypass may be necessary, which may be venous or arterial. Arterial bypasses have better long-term patency; however, they are a source of donor-site complications. We carried out an anatomical study on 11 upper limbs and 7 lower limbs from cadavers to identify a technically accessible arterial graft, of a diameter suitable for bypassing the ulnar artery in Guyon's canal and with acceptable scar sequelae (few predicted postoperative complications, discreet size and/or location of scar). Three grafts were considered: anterior interosseous artery, radial recurrent artery and descending genicular artery. The various grafts were dissected and harvested from cadaver specimens, then their lengths and diameters were measured. The diameter of the candidate grafts was compared to the diameter of the distal ulnar artery. The diameter of the descending genicular artery matched the ulnar artery better than the radial recurrent artery or the anterior interosseous artery (103% vs 44% and 67%, respectively). Mean graft length was 6.6 cm. The anatomical configuration of the descending genicular artery allowed Y-shaped bypasses to be performed. Harvesting this artery appears to cause little damage and allows bypasses up to 6 cm to be performed. Despite its smaller diameter making it necessary to perform a microvascular size adjustment, the anterior interosseous artery is a candidate graft because it is long enough (119 mm) and located near the surgical site. LEVEL OF EVIDENCE: V.

Diagnosis and Management of a 4-Year-Old Male with Ulnar Artery Pseudoaneurysm

Background

Pseudoaneurysms are a rare vascular phenomenon caused by an intimal tear leading to hemorrhaging into surrounding tissue. Upper extremity pseudoaneurysms are well documented in adult patients and are attributed to repetitive trauma. Pediatric pseudoaneurysms are rare and are frequently misdiagnosed, which could lead to serious complications.

Methods

This report presents the case of a 4-year-old male patient with an ulnar pseudoaneurysm of the right upper extremity. The pseudoaneurysm was diagnosed by ultrasound and computed tomography angiography and subsequently resected. The ulnar artery was reconstructed with an arterial graft using the descending branch of the lateral circumflex femoral artery. Patency of the end-to-end anastomosis was confirmed by strip testing and Allen's test.

Conclusions

The aim of this report is to provide a background of upper extremity pseudoaneurysms and describe their rare occurrence in pediatric patients and potential for complications upon misdiagnosis. Additionally, this report aims to highlight an alternative approach to management of pediatric pseudoaneurysms and advocate for reconstruction of the affected artery regardless of collateral flow being established.