RR25. Infracarpal Upper Extremity Arterial Bypass: Is it Worth it?

Abstract

Patients presenting with digital ischemia and arterial occlusion distal to the wrist are a disadvantaged population with renal failure, collagen vascular disease and hypercoaguable states and difficult technical options for revascularization. A nonaggressive stance to treatment in these patients often leads to significant digit/hand loss and thus we have approached these patients aggressively in order to try to improve limb salvage. A retrospective review of all upper extremity bypasses performed to arteries distal to the wrist was performed. All patients were evaluated with biplanar arteriography. Patients with hypercoaguable states and rheumatoid arthitides/collagen vascular disease (RA) were medically evaluated prior to operation. Postoperative surveillance was performed with PVR and Duplex scan. Vein bypasses were performed in all cases. Patency was computed according to life table methods. Between 1993 and 2008, 40 bypasses were performed in 34 patients for digital gangrene (20), rest pain (13) and ulcer (5). There were 19 males and 15 females. Patient risk factors included diabetes (17), active smoking (17), hypertension (13), hyperlipidemia (8), Coronary disease (10) and renal failure (18). Documented hypercoaguable states and RA were present in four and 12 patients, respectively. Outflow arteries included distal radial (29), distal ulnar (1), palmar arch (7) and common digital arteries (3). Venous conduit included saphenous and cephalic veins in reversed (34), nonreversed (3) and spliced (3) configuration. There was no operative mortality. Digital amputation was performed in 19 patients for gangrene and minor debridement in 4 patients. There were 5 bypass occlusions all of which occurred in the first year. Cumulative patency from this point on was 84% (mean follow up: 22 months (range: 1-184 months)). Cumulative survival was 57% at 2 years and 26% at 5 years. Arterial bypass in patients with infracarpal upper extremity arterial disease is challenging but may be achieved with excellent patency. Digital amputation is often required. Long term survival in these patients is limited and perioperative management of patient risk factors important.