Endovascular Intervention of Critical Limb-Threatening Ischemia of the Upper Extremity with Gangrene: A Case Study

L. Raja, A. Valles

Purpose: Limb preservation through endovascular intervention of the right upper extremity with critical limb-threatening ischemia (CLTI), Rutherford class VI with gangrene to the fingers

Materials and Methods: Peripheral interventional procedure performed, a 4-Fr JR4 catheter was advanced through the femoral sheath into the subclavian artery and then advanced into the brachial artery. Next the JR4 was exchanged with a 6-Fr multipurpose guide advancing into the brachial artery. Angiography of the right upper extremity was performed, which showed that the right brachial artery was patent distally, and the large ulnar artery was total occluded proximal to the wrist. The radial artery was completely occluded and not visible. The patient’s only blood supply came from one single collateral artery to the palmar arch. There was reconstitution of the ulnar artery in the middle portion of the palm. Next, 0.14 angled TrailBlazer along with 0.014 Advantage wire was advanced into the occlusion of the ulner artery but was unable to go through it. Under ultrasound access obtained at the reconstituted ulnar artery in the palm, a 0.18 wire was advanced successfully retrogradely crossing the occluded ulnar artery, continuing up to the reconstituted ulnar artery. Then through this access, percutaneous transluminal angioplasty was performed with a coronary balloon but was unable to get antegrade wire following tract. A snare was advanced through the micropuncture sheath from the hand, and the antegrade wire was snared and brought into the palmar sheath. Then the wire was advanced through the palmar sheath and removed. The antegrade wire was advanced down into the digital branches, and a balloon was advanced, crossing all the occlusion and puncture site and inflated for 15 and then 10 minutes.

Results: There was recanalization of the ulnar artery with extensive great flow to the digits. There was no evidence of further bleeding or perforation. The patient was free of pain and discomfort immediately after the procedure.

Conclusions: CLTI of the upper extremity, although less common than lower extremity ischemia, is just as threatening and deadly. The endovascular approach has many offerings and challenges to revascularization. With the cases in upper extremity critical limb ischemia rising, new and novel techniques and devices in these procedures are imperative to save both upper and lower extremities and to save lives.