Arterialization of the Venous System for Acute and Chronic Ischemia of the Hand: A Case Series With Prospective Duplex Ultrasound Assessment

Abstract

Background: Ischemia of the hand is a debilitating condition. In many cases, the cause of ischemia is diffuse atherosclerosis with no distal vessels available for bypass. In these situations, options are limited to restore perfusion, and there is a potential role for arterialization of the venous system to relieve ischemic pain and avoid amputation. Methods: This is a retrospective review of all patients at our institution who underwent arterialization of the venous system between 2010 and 2014 by 4 surgeons for acute or chronic ischemia of the upper extremity not amenable to bypass procedures. Indications, preoperative and postoperative findings, and the requirement for future digital amputations were recorded. The patients were then evaluated prospectively for the patency of arteriovenous anastomosis and the pattern of perfusion by duplex ultrasound studies. Results: Eight patients with 10 upper extremities underwent arterialization of the venous system. All patients with chronic ischemia went on to heal their ischemic ulcerations with relief of rest pain and avoided amputation. Eight upper extremities had arterial Doppler and duplex ultrasound signals showing arterialized dorsal veins demonstrating flow from the dorsal veins heading volar via the intrinsic compartments into the digital arteries. Conclusions: This study illustrates the successful use of arterialization of the venous system of the hand in both acute and chronic hand ischemia. It reports on prospective imaging and duplex ultrasound studies confirming patency of the anastomosis and objective evidence of distal arterial flow. Based on our experience, we believe that arterialization of the venous system may provide an effective salvage option in the setting where no distal bypass is available.

Introduction

Upper extremity ischemia is significantly less common than ischemia of the lower extremity. Despite this, an upper extremity surgeon is likely to encounter acute or chronic upper extremity ischemia at some point in his or her practice. Therefore, it is important to have an approach to this issue. Ischemia of the upper extremity can result from a variety of etiologies, including peripheral vascular disease, collagen vascular disease, embolic disease, or vascular thrombosis.¹ Upper extremity amputations are poorly tolerated and have greater functional consequences on quality-of-life outcomes when compared with amputations of the lower extremity.² Therefore, when possible, all attempts should be made to restore perfusion to avoid impending amputation. Restoring perfusion has the additional benefit of relieving ischemic rest pain and improving wound healing capacity—2 of the main complaints of patients with upper extremity ischemia.

After a thorough history and physical examination, the underlying cause of ischemia must be sought. If there is a fairly localized and proximal area of occlusion, then the treatment of choice is a bypass procedure to a patent more distal vessel past the point of blockage. Any ischemia resulting from vasospastic disease such as Raynaud phenomenon should be treated with appropriate vasodilatory medications, botulinum toxin injections, or surgical sympathectomy. However, these interventions may be inadequate to reverse the ischemic process, and alternative treatment may be needed to attempt digit preservation. Unfortunately, in many of these cases of upper extremity ischemia, the patients have multiple medical comorbidities such as diabetes, hypertension, and end-stage renal disease and are often heavy smokers. Commonly, the cause of underlying ischemia is diffuse atherosclerosis, and no patent distal vessels are available to perform a bypass procedure. In these situations, options are limited to restore perfusion and there is a potential role for arterialization of the venous system.

It has previously been theorized that arterialization of the venous system produces valvular incompetence with arterial inflow passing through arteriovenous shunts into the capillary beds. Studies of ischemic limbs in animal models have demonstrated neovascularization and increased oxygen tension following arterialization of the venous system.^3,4 In our practice, arterialization of the venous system has a role in situations of irreversible acute and chronic upper extremity ischemia. It can be used as a salvage procedure and can improve perfusion, pain control, and wound healing capacity of the involved extremity with relative ease and short operative time. Arterialization of the venous system of the lower extremity was first performed by Carrell in 1902.⁵ Following this initial report, several other cases were reported, but the procedure was abandoned due to high complication rates associated with arterialization of the venous system in the lower extremity.^6-8 Since then, arterialization of the venous system of the upper extremity has regained attention. The principle of arterializing a venous system has proven successful in several microsurgical pursuits such as the use of venous flow through flaps^9,10 and documented success of digital replantation¹¹ based on arterialized veins of the replanted digit with no arterial-to-arterial anastomosis. This principle prompted a regain in the idea of arterialization of the venous system to restore perfusion in the upper extremity.^12,13 Kind reported the resolution of ischemic rest pain following the procedure in 5 hands in 3 patients.¹⁴ Chloros et al showed a 7-year follow-up on a single hand salvage using the procedure with good long-term results.¹⁵ Hammert et al performed arterialization of the venous system in 10 patients for ischemic ulcerations. All patients in their case series went on to heal their ischemic wounds.¹⁶

The purpose of this article is to report on our experience of arterialization of the venous system of the upper extremity for both acute and chronic ischemia of the hand and to demonstrate its clinical utility in regard to limb salvage and the decreased need for future digital amputations. Our secondary purpose was to demonstrate anastomotic patency and the presence of distal arterial inflow via the venous system to the digits on duplex ultrasound studies.

Methods

This is a retrospective review of all patients at our institution who underwent arterialization of the venous system of the involved upper extremity between 2010 and 2014 by 4 senior surgeons. Indications for surgery were recorded in addition to preoperative patient demographics. These included age, comorbidities, smoking status, and the presence of ischemic rest pain and digital ulcerations. See Table 1 for patient demographics.

Table 1.

Demographics of Patients Who Underwent Arterialization of the Venous System of the Hand.

Age	Comorbidities	Smoker	Diagnosis	Symptom duration	Ulceration present	Ischemic pain
75	T2DM, PVD	Yes	Right hand ischemia (D4/D5)	3 d	No	Yes
53	Buerger disease	Yes	Left hand ischemia (D2/D3)	2 wk	Yes	Yes
51	HTN, CKD	Yes	Left hand ischemia (D1/D2)	1 mo	Yes	Yes
52	Raynaud phenomenon, HTN	Yes	Right and left hand ischemia	1 y	No	Yes
62	HTN, hypercholesterolemia	Yes	Right and left hand ischemia	1 y	Yes	Yes
33	IVDU, depression	No	Right hand ischemia (D1/2/3/4) secondary to intra-arterial Gravol injection	3 d	No	Yes
62	T2DM, CKD, HTN	Former	Right hand ischemia (D2/D3)	2 mo	Yes	Yes
54	T2DM, CKD, HTN, CAD	Yes	Right hand ischemia	4 mo	Yes	Yes

Note. T2DM = type 2 diabetes mellitus; PVD = peripheral vascular disease; HTN = hypertension; CKD = chronic kidney disease; IVDU = intravenous drug use; CAD = coronary artery disease.

To be considered a candidate for arterialization of the venous system, the patient had to have a clinical diagnosis of ischemia, demonstrating pain, pallor, and decreased capillary refill, or the presence of digital ischemic ulceration on examination. All patients had distal arterial occlusions deemed not amenable to a bypass procedure that were confirmed by preoperative imaging with a conventional angiogram in addition to their clinical diagnosis. The patients did not have formal preoperative pulse oximetry measurements. The diagnosis of ischemia was a clinical one based on physical examination and the imaging studies mentioned above.

Average operative time, estimated blood loss, and any minor or major surgical complications were recorded. The patients were then seen postoperatively at 1 week, 2 weeks, 6 weeks, and 3 months as needed. At 1-year follow-up, the patients were evaluated prospectively for the patency of arteriovenous anastomosis and the pattern of perfusion by duplex ultrasound studies. We also recorded postoperative pulse oximetry measurements on the operative hand, the need for future digital amputation, the presence of postoperative ischemic pain, and the absence or presence of healing of digital ulcerations. This study was a retrospective chart review, so informed consent was not obtained as per our institution’s review policy on retrospective reviews.

In all cases, the cephalic vein was anastomosed in an end-to-side fashion into the radial artery at the vicinity of the wrist. We decide on the location of anastomosis by directly examining the radial artery and finding an area free enough of disease and pliable enough for a safe anastomosis to be performed. If the radial artery is explored and there is no area of vessel that is amenable to an anastomosis, then the wound is closed and the procedure terminated. An 8′0 nylon suture is used to perform the end-to-side anastomosis (see Figure 1). The procedure is done under regional anesthesia with the use of a Bier block. We do not use a valvulotome as our anastomosis is being done around the level of the wrist. We rely on arterial pressure to induce valvular incompetence. The adequacy of arterial pressure to overcome the venous valves is inferred by the presence of pulsatile flow on arteriotomy of the radial artery. Patients are placed in a wrist neutral splint with their fingers and metacarpophalangeal (MCP) joints free for 2 weeks postoperatively. We instruct all patients that they should avoid any venipuncture to the dorsum of their hand due to arterial flow and associated bleeding risk.

Figure 1.

Case example of a patient with acute on chronic ischemia of the left hand and dry gangrene. The patient underwent concomitant arterialization of the venous system of the cephalic vein end-to-side to the radial artery along with revision amputation of the left middle finger.

Results

Eight patients with 10 upper extremities underwent arterialization of the venous system. The mean age was 55 years. Of the 8 patients, 7 (88%) were smokers, and 6 (75%) were currently smoking at the time of surgery. Etiology of upper limb ischemia was atherosclerosis in 6 hands (60%), Raynaud phenomenon in 2 hands (20%), Buerger disease in 1 (10%), and thromboembolic occlusion from intravenous drug use in 1 (10%). The duration of symptoms were acute (<1 week) in 2 cases (25%) and chronic (>1 week) in 8 cases (80%). The 2 patients in the study who had both hands operated on had initially presented with ischemia worse on one side. Postoperatively, they were so satisfied with the outcome of the procedure that they requested the contralateral side to be operated on. This included both a patient with Raynaud phenomenon and a patient with chronic ischemia secondary to atherosclerosis.

Average operative time was 98.6 minutes with <50 mL of estimated blood loss. Average follow-up was 11 months (range, 2-17 months). No patients in the study showed any evidence of progression of ischemia. No minor or major complications were seen in this series. All patients with chronic ischemia and digital ulcerations had went on to heal their ulcerations within the duration of follow-up, although the time to ulcer healing was not recorded. Two patients presenting with acute ischemia (<1 week) required fingertip amputations for resultant ischemic changes that were irreversible despite arterialization of the venous system of the involved upper extremity. One of these patients was a 36-year-old woman, pregnant at the time of the acute event. Her medical history was significant only for depression and prior intravenous drug use. She sustained acute ischemia to the hand following injection of intravenous Gravol into the right hand. Prior to this acute insult, her vascular system was presumed to have been normal. The other patient presenting with acute ischemia was a 75-year-old male diabetic vasculopath presenting with acute on chronic ischemia of the right hand.

Although pain scores were not quantified using a visual analog scale or recording the amount of pain medication taken, all patients in the study reported decreased pain within 1 to 2 weeks following surgery, with 6 (75%) patients reporting pain relief within days of the procedure.

Eight of the 10 hands in the study were prospectively evaluated using pulse oximetry and duplex ultrasound at an average of 11 months postoperatively. The other 2 patients did not undergo duplex ultrasound studies as this study was initially done to include the original 8 patients and show that there was volar and distal arterial flow. The additional 2 patients were included to provide further information on our experience with arterialization of the venous system of the hand during the time of preparation of this article. All 8 had arterial Doppler and duplex ultrasound signals at the site of anastomosis (Figure 2), the dorsal veins in the hand and at least one digital artery all the way up to the pulp. All digits of every hand had an oxygen saturation greater than 94%. Arterialized dorsal veins could be seen, demonstrating flow by duplex ultrasound from the superficial dorsal veins heading volar via the intrinsic compartments in all imaged extremities (Figure 3). One of the patients in the study underwent a postoperative computed tomographic angiogram at greater than 1 year postoperatively, demonstrating arterial flow in the venous system (Figure 4).

Figure 2.

Duplex ultrasound demonstrating arterial flow at the anastomosis from the radial artery to the cephalic vein at the level of the wrist.

Figure 3.

Duplex ultrasound demonstrating flow from the superficial venous system volarly via the intrinsic compartments: sagittal (a) and coronal (b).

Figure 4.

One-year postoperative computed tomographic angiogram of right hand demonstrating arterial flow from the radial artery into the arterialized venous system.

Discussion

With an aging population and high rates of diabetes, end-stage renal disease, and peripheral vascular disease, practicing upper extremity surgeons are likely to receive consultations for upper extremity ischemia that is not amenable to a bypass procedure. In those cases, few options exist to restore distal perfusion. This study on a series of 10 hands that underwent arterialization of the venous system demonstrates effectiveness of the procedure for salvage of both the acute and chronically ischemic hand. Following this procedure, patients demonstrated significant symptom resolution, improved pain control, and evidence of improved distal perfusion both by clinical examination and by duplex ultrasound studies. The patient with Raynaud phenomenon as well as the patient in the study with Buerger disease felt such significant relief postoperatively that they returned to clinic to request for the same procedure on the contralateral side. Although Buerger disease is known to affect the venous system as well, the patient in our study still had success with arterialization of the venous system, despite the potential contraindication to the procedure. The only patients in this series who required finger amputations were those who presented with acute (<1 week) ischemic changes. Due to the acute nature of the ischemia, it is likely that the tissue in these cases was less resilient to ischemic changes and the process was not able to be reversed, despite improved distal perfusion. These patients likely relied on traditional patterns of blood flow compared with patients with chronic ischemia who would have had time to create alternative collateral channels of perfusion. In our series of 10 patients, we did not have any minor or major complications noted, other than the amputations seen in the 2 patients with acute ischemia. The most common complaint reported by patients is the audible bruit that can be heard if the patient sleeps with the involved hand under their head.

Management of patients with chronic ischemia of the upper extremity is difficult with limited options. Arterialization of the venous system appears to be a reliable procedure to relieve ischemic symptoms and allow for wound healing. Kind¹⁴ published their experience on 5 hands in 3 patients, with pain relief and wound healing demonstrated in all hands in the study. King et al¹² treated 5 patients with arterialization of the venous system and noted improved symptoms at 22-month follow-up. Hammert et al¹⁶ reported on 10 cases, all with improved pain control and complete wound healing. No other series reported in the literature have prospectively evaluated distal perfusion by confirming patency of the anastomosis and improvement in distal arterial flow with imaging studies—in this case, duplex ultrasound. This study provides prospective confirmation by duplex ultrasound studies of both anastomotic patency and evidence of arterial flow until, on average, at least 1 year postoperatively. The long-term patency of the anastomosis beyond this point in time is yet to be determined. Long-term follow-up and repeat imaging studies on these patients would be required to determine the long-term patency rates beyond this 1-year window.

Zeng and Hammert¹⁶ report using the brachial artery as the source of inflow and utilizing a valvulotome to strip the valves off the cephalic vein. They prefer the brachial artery as they have noted weak inflow when performing the procedure with the use of the radial artery. We have never used the brachial artery, only the radial artery, as the inflow vessel. We do not use a valvulotome as the anastomosis is being done down at the level of the wrist. We then rely on the arterial pressure through the venous system to induce valvular incompetence. We have had no issues with this technique and have achieved good results as illustrated in this study.

This study has some obvious limitations. Of great note is the relatively small sample size. However, this is comparable to other case series looking at arterialization of the venous system. Due to the relative rarity of the clinical problem, a large prospective study would be difficult to perform. There is also a need for long-term follow-up to assess these patients prospectively for anastomotic patency, complications, and need for any further digital amputations or new digital ulcerations. Another notable weakness is the heterogeneity in the population of patients presented in this study. This again is reflective of the relative rarity of the clinical problem. It would be difficult to get a large enough cohort of patients to individually analyze outcomes according to individual disease processes. One further limitation is the fact that only 8 of the 10 patients in our study underwent ultrasound examinations. Ideally, all 10 patients would have had these studies performed to provide stronger support for the demonstrated patency of the anastomosis with evidence of distal arterial flow.

Given the encouraging results seen in this study and the often limited improvement seen in cases of severe arterial disease with attempts at segmental arterial bypasses, it may be worth asking whether or not there is a role for earlier attempts at arterialization of the venous system of the hand than is currently in practice.

Conclusions

This study illustrates the use of arterialization of the venous system of the upper extremity in both acute and chronic upper extremity ischemia. It reports on prospective imaging and duplex ultrasound studies confirming both patency of the anastomosis and objective evidence of distal arterial flow. Based on our experience, we believe that arterialization of the venous system may provide an effective salvage option in the setting where no distal bypass is available.