Ten patients are presented who underwent treatment for ischemic changes of the hand not responsive to medical management. Underlying diagnoses included diabetes with renal failure, Raynaud's syndrome, and subclavian artery compression with distal emboli. All patients were treated with tPA or angioplasty and failed. Preoperative angiography was performed on all patients. All patients presented with a chief complaint of severe ischemic pain. Seven of ten had digital ulcerations. In all ten patients upper extremity bypass was performed with reversed vein grafts with end-to-side proximal anastomoses to the radial or ulnar arteries and end-to-side distal anastomoses to the deep or superficial arches or the dorsal radial artery. Patency rates were initially 80% in the first three months, and all patients had immediate relief of ischemic pain. All ulcers healed and gangrene resolved in all 4/10 patients with preoperative gangrene. Long-term patency rates were low, with only 33% of grafts remaining patent at one year. Despite this, 7/8 patients still alive at one year had continued relief of symptoms. Two patients died in the postoperative period, both having gained control of their ischemic pain following surgery, until they succumbed to their underlying disease.
The authors conclude that proximal and distal end-to-side anastomoses for treatment of digital ischemia is preferable to sympathectomy alone or other methods of revascularization in patients with distal ischemic symptoms due to arterial occlusion. The benefits cited are greater distal vessel size in reversed vein grafts with a larger area of distal revascularization and a single distal anastomosis with shortened operative time. A limited arch sympathectomy was necessary in preparation of the distal anastomosis, which may have helped to maintain short-term patency. They achieved significant symptom relief in a challenging patient population with limited life expectancy and very advanced arterial disease. Their long-term results show that alterations in distal blood flow sufficient to relieve ischemic symptoms occur routinely after revascularization, despite low rates of patency in the bypass graft itself.
J Reconstructive Microsurgery