Symptomatic ischemia resulting from late upper extremity venous graft occlusion

Abstract

Summary Reconstruction of traumatic or occluded vessels with vein grafts to treat ischemia of the hand is common in current upper-extremity surgery. Late symptomatic occlusion of the venous graft, however, has seldom been reported. We report two cases involving patients who developed acute symptomatic ischemia in their hands from occlusion of their vein grafts > 15 years after their initial surgery. Our management strategy was additional arterial reconstruction. An extensive review of the literature on late vein graft occlusion in the upper extremity was performed to compare presentations, management strategies, and outcomes for this disease. In both cases, computed tomography angiogram results confirmed clinical suspicions of late venous graft occlusions. Conservative management was attempted first with no resolution of symptoms. Repeated arterial or venous grafting was performed to bypass the diseased segments. PubMed searches with the separate key phrases “late graft occlusion”, “late vein graft occlusion”, and “late vein graft occlusion hand” were entered. Titles and abstracts were filtered and relevant full texts were reviewed. Limited studies have been reported on symptomatic late vein graft occlusions of the upper extremity. Experimental studies have shown that intra-arterial microvenous grafts undergo the same vessel remodeling as macrovenous grafts in animal models. The same mechanism of neointima proliferation and subsequent atherosclerotic events were considered the main causes of graft occlusions in these cases. After regrafting, their symptoms subsided during follow-ups at 1 year and 6 years, respectively. We present two rare clinical case reports of patients who suffered ischemic symptoms in their hands from late (> 15 years) occlusion of vein grafts. Both patients were assessed with preoperative computed tomography angiograms and successfully treated with regrafting. In cases of late occlusion with ischemic symptoms, a repeat arterial reconstruction with venous or arterial grafting is recommended.