Upper extremity arterial bypass distal to the wrist

Abstract

Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold. All lesions in patients with digital ischemic ulcerations healed, and all patients experienced relief of rest pain. Three patients with patent grafts have residual symptoms of Raynaud's disease in the ipsilateral hand but are otherwise free of symptoms. Two patients died of end-stage renal disease at 7 and 19 months after operation. Both had patent grafts and well-perfused hands. On the basis of this experience, we believe that patients who have embolizations to the digital circulation from an ulnar aneurysm may be considered for aneurysm excision and interposition grafting. Patients with end-stage renal disease and critical hand and finger ischemia who are facing digital amputation because of the ischemia should be considered for detailed hand arteriography to assess the potential of bypassing the arterial obstruction with a distal anastomosis in the palm. A variable but small number of these patients may experience significant symptomatic relief from such procedures.