ABSTRACT: Purpose: Endovascular interventions in the arm can be essential in saving an affected limb. A difficult case of ulnar occlusion is described. Case Report: A 69-year-old male was referred to the clinic with gangrenous changes to the right first and second fingers. The patient had a variety of comorbidities and a recent history of mitral valve replacement. Angiography identified a total occlusion of the ulnar artery and limited flow to the hand. Atherectomy was performed using an orbital atherectomy system and a balloon was passed and inflated in the interosseous artery. Excellent flow was obtained into the hand; however, there was no flow in the gangrenous portion of the digits. The patient returned 10 days later for partial amputation of the fingers but has had no revascularization and no new wounds on the treated forearm. Conclusion: This case illustrates the benefit of endovascular intervention in patients with forearm and hand occlusions.

VASCULAR DISEASE MANAGEMENT 2016;13(4):E95-E100

Key words: orbital atherectomy, ulnar artery, limb salvage, endovascular therapy

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Occluded vessels in the upper extremity are most often treated with amputation of the affected digits or hand and, less frequently, surgical bypass is performed to restore blood flow. Amputation carries many risks and results in permanent disability for the patient. Surgical interventions of occluded vessels have focused on bypass grafting, often from the saphenous vein;¹ however, these techniques are invasive, carry risks of infection, and may result in a longer recovery time. Superficial grafts distal to the wrist should also be carefully considered because the hand is particularly prone to trauma, and grafts may be more likely to become occluded due to flexion and extension of the hand.² Neither amputation nor surgical bypass is ideal for every patient and new endovascular treatment options are being used in the forearm.

Endovascular treatment of the forearm is difficult due to small vessel size; however, this treatment option is similarly as challenging as endovascular intervention below the knee. The right and left ulnar arteries have average diameters of 2.3 mm and 2.4 mm, respectively, and the right and left radial arteries have average diameters of 2.3 mm and 2.2 mm, respectively.³ Comparatively, these vessel sizes are similar to those found below the knee, but larger than those found below the ankle. Physicians are beginning to treat chronic hand ischemia patients with percutaneous transluminal balloon angioplasty.^4,5 Balloon angioplasty is prone to higher rates of restenosis;⁶ therefore, atherectomy is a combined therapy often employed in the periphery. In many cases, atherectomy is not typically considered due to the small anatomy of vessels in the forearm; however, the orbital atherectomy system (OAS) (Cardiovascular Systems, Inc.) can enter vessels with reference vessel diameters as small as 1.5 mm. As below-the-knee interventions are gaining popularity,^7,8 physicians are hopeful that the need for interventions in the upper extremity will become more apparent. This case details the use of atherectomy in the interosseous ulnar artery.

Case Report

A 69-year-old male was referred to the clinic with pain and gangrenous changes in the first and second fingers of the right hand. He had a history of obesity, diabetes, and hypertension; he recently underwent a mitral valve replacement and had an identified thrombus in his jugular vein. The primary care physician identified that the patient’s right hand was swollen and capillary refill was absent in the first and second fingers. The primary care physician was pessimistic about the ability to save the patient’s first and second fingers, but hopeful that more proximal tissue could be saved depending on the location of the occlusion. 

Angiography identified a total occlusion of the radial artery and an occlusion in the interosseous ulnar artery (Figure 1A) and flow to the hand was poor (Figure 1B). Endovascular intervention was performed in an effort to salvage the patient’s right hand and affected digits. Using the modified Seldinger technique, a 6 Fr sheath was placed in the brachial artery. A total occlusion in the right radial artery was crossed and treated by with 2.5 mm x 30 mm Apex balloon (Boston Scientific). Treatment resulted in less than 20% residual stenosis. Brisk anterograde flow was restored to the fingers and attention was turned to an occlusion in the interosseous ulnar artery (Figure 1A). A Prowater wire (Asahi) was used to transverse the stenosis. The Prowater wire was exchanged for a ViperWire (Cardiovascular Systems, Inc.) and a 1.25 mm (145 cm shaft length) Diamondback 360 Peripheral OAS (Cardiovascular Systems, Inc.) was advanced over the wire into the interosseous ulnar artery (Figure 2A). Sequential atherectomy passes were performed and the catheter was removed and exchanged for a tapering 2.5 mm x 210 mm NanoCross balloon (Covidien) (Figure 2B). Following balloon angioplasty, there was an improved angiographic result with restoration of flow into the hand and third and fourth fingers, as well as less than 30% residual stenosis of the interosseous ulnar artery (Figures 3A and 3B). However, flow to the diseased fingers was still poor, suggesting that necrosis was fairly advanced or additional occlusions were present within the digits. The procedure was well tolerated by the patient, with no acute procedural complications and positive angiography results were achieved at the conclusion of the interventions. 

The patient returned for a follow-up appointment 10 days after the index procedure; both the first and second fingers remained gangrenous and necrotic. The patient was scheduled for a partial amputation of the two fingertips and the procedure was carried out. The patient had good healing of the amputated fingertips (Figure 4) and maintains full use of his hand. The patient has been followed for over 1.5 years and has not returned to the clinic for additional endovascular or surgical interventions to the right forearm.

Discussion

Occluded arteries in the upper extremity can be especially debilitating because hand and digit amputations may severely impact a patient’s lifestyle and ability to work. Hand and digit amputations can cause extreme stress for patients, which sometimes develops into post-traumatic stress disorder, and these symptoms could be brought on simply by visualizing the traumatized body part.⁹ Endovascular treatments of hand and forearm occlusions are possible and they can reduce or even prevent the need for amputations. There are many reasons to consider endovascular intervention for the occluded upper extremity. Because of the amount of flexion and extension of the hand and forearm, bypass grafts are not ideal and may be prone to additional wear.² Patients with wounds and poor blood flow are sometimes unsuitable candidates for surgery because the additional wound may not heal correctly or could become infected.¹ Endovascular treatment of the upper extremity is still gaining popularity; however, recent below-the-elbow studies have shown that angioplasty is safe.¹⁰ A recent literature review and case study also highlighted the value of endovascular approaches in the upper extremity — the authors note that patients with diabetes, end-stage-renal-disease, and systemic atherosclerosis are more likely to suffer from occlusions in the forearm and hand.¹¹ These conditions may hamper the development of rich collateral that usually supplies the hand and forearm when occlusions are present in main arteries.¹¹ The patient in this case summary suffered from systemic atherosclerosis.

With the increasing prevalence of atherosclerosis, vascular calcification also presents a challenge in identifying the best course of treatment.¹² Balloon angioplasty has a high rate of restenosis: in the study of angioplasty below the elbow, 18% had restenosis during a 13±9 month follow-up period.10 However, drug-eluting technologies are lagging in their introduction to the upper extremity. Drug-eluting stents are too large to fit below the elbow and drug-coated balloons have shown poor results in more distal vessels.¹³ Additionally, recent results suggest that drug delivery is hampered in the presence of calcium.¹⁴ For these reasons, vessel preparation may be necessary in order to lessen the high restenosis rate with balloon angioplasty treatment. In this case, the lesion was treated with an OAS prior to balloon angioplasty, and this provided a positive result. To our knowledge, this is the first published case of atherectomy in the occluded forearm. Atherectomy may provide an alternative to balloon angioplasty alone and could be a suitable combined therapy as new technologies emerge.

Conclusion

This patient was successfully treated using an OAS, and flow to the hand was restored after intervention. This case illustrates the utility of peripheral intervention to reduce the severity of amputation in occluded vessels of the hand.

Editor’s note: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Dishmon reports receiving travel reimbursement from Cardiovascular Systems, Inc.

Manuscript received September 29, 2015; manuscript accepted January 21, 2016.

Address for correspondence: Dwight Dishmon, MD, UT Methodist Physicians, The University of Tennessee Health Science Center, 920 Court Avenue, Memphis, TN 38163, USA. Email: dwightdishmon@gmail.com.

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