Occlusion Of Digital Arteries Research Articles

Odd Aspects of Hemochromatosis, a Widespread Disease

Odd Aspects of Hemochromatosis, a Widespread Disease Abstract. This case series is written to investigate the odd aspects of hemochromatosis, a frequently encountered disease in our latitudes (and even a widespread disease in Ireland). One patient presented with bilateral digital artery occlusion and another one with bilateral rib fractures. Quite often, hemochromatosis comes with a surprise.

Hand-arm vibration syndrome with distal brachial artery occlusion

Abstract Hand-arm vibration syndrome (HAVS) is a complex disorder of the peripheral extremities that is associated with occupational or recreational exposure to hand-transmitted vibration. Digital artery occlusion in HAVS is a common finding; however, proximal involvement is less likely. We present a case of HAVS with the initial presentation of acute limb ischemia and with thrombus burden extending from the distal brachial artery and into the ulnar and radial arteries. To our knowledge, no case of HAVS syndrome of similar severity has been previously described. This case emphasizes the potential dangers of HAVS and the necessity for proper prophylactic interventions at the workplace.

外傷性急性尺骨～固有指動脈閉塞に対し，選択的動注線溶療法が著効した1 例

外傷性急性尺骨～固有指動脈閉塞に対し，選択的動注線溶療法が著効した1 例

Systemic sclerosis presenting with severe digital ischemia: A rare case report

Digital ischemic loss is a cause of significant morbidity in patients with systemic sclerosis (SSc). Both small and large digital arteries are involved causing perfusion defects leading to ischemia. Microvascular disease causes intimal proliferation and luminal narrowing of small digital arteries, macrovascular disease causes narrowing or occlusion of larger digital arteries. Immediate clinical evaluation and treatment are mandatory at the onset of critical digital ischemia to prevent digital loss. We present a case of 38-year-old female suffering from SSc who presented with acute onset severe digital ischemia of all four limbs.

Clinical analysis of leg ulcers and gangrene in rheumatoid arthritis

Leg ulcers are often complicated in patients with rheumatoid arthritis (RA), however, the etiology is multifactorial. We examined the cases of leg ulceration or gangrene in seven RA patients who were hospitalized over the past 3years. One patient was diagnosed as having pyoderma gangrenosum. Although vasculitis was suspected in three patients, no histological evidence was obtained from the skin specimens. In these patients, angiography revealed the stenosis or occlusion of digital arteries. In the remaining three patients, leg ulcers were considered to be due to venous insufficiency. Treatment should be chosen depending on the causes of leg ulcers.

Etiology of ‘blue toe’ syndrome: Emboli versus warfarin therapy. Report of a case

Abstract ‘Blue toe syndrome’ presents as a cyanotic toe caused by fibrino-platelet micro-emboli occlusion of the small digital arteries, with palpable pedal pulses originating from a proximal atheromatous source (cardiac, aortic, femoral or popliteal aneurysm). We report a case in a 43-year-old woman with a history of hypertension and diabetes. She was taking warfarin for extensive right deep-vein thrombosis 6 months before her current admission. She presented with sudden onset of severe pain, parasthaesia and bluish discolouration of the right big, second and third toes, in spite of palpable distal pulses. Computerized tomography angiography revealed an atheromatous plaque causing 70% stenosis of the infra-renal aorta. We therefore performed aortotomy, thrombectomy and endartectomy. Blue toe syndrome is of clinical importance in etiology, diagnosis and treatment. Our case had blue toe syndrome despite anticoagulant therapy.

Acute palmer digital artery occlusion treated using endoscopic ablation of the thoracic sympathetic.

Acute occlusion of the digital arteries frequently causes painful infarction requiring digital amputation. We describe a 55-year-old male patient who presented with acute onset of digital ischemia with impending gangrene on the right hand. Because angiography revealed bypass surgery was not feasible, he underwent thoracoscopic sympathectomy (TS) one week after onset of the symptom, which resulted in rapid pain resolution. He was diagnosed, thereafter, with malignant rheumatoid arthritis and methotrexate was administered. Postoperative angiography revealed that the occluded digital artery had become recanalized. Timely TS is therefore a treatment of choice for acute digital ischemia.

Digital Ischemic Loss in Systemic Sclerosis

Digital ischemic loss is a cause of significant morbidity in patients with systemic sclerosis (SSc). Microvascular disease with intimal proliferation and luminal narrowing of small digital arteries, as well as macrovascular disease with narrowing or occlusion of larger digital arteries, contribute to the perfusion defects involved in digital ischemic loss. Immediate clinical evaluation and treatment are mandatory at the onset of critical digital ischemia to prevent digital loss. Hospitalization for medical therapies including intravenous prostacyclin therapy should be considered for all SSc patients who present with critical digital ischemia. Surgical interventions are typically reserved for patients who fail medical therapies and for those with late stage, necrotic tissue. This paper summarizes the current knowledge regarding the risk factors, pathogenesis, evaluation, and treatment of digital ischemic loss in SSc.

Acute Palmar Digital Artery Occlusion Treated Using Endoscopic Ablation of the Thoracic Sympathetic Ganglia: Report of a Case

Acute occlusion of the digital arteries frequently causes painful infarction requiring digital amputation. We describe a 55-year-old male patient who presented with acute onset of digital ischemia with impending gangrene on the right hand. Because angiography revealed bypass surgery was not feasible, he underwent thoracoscopic sympathectomy (TS) one week after onset of the symptom, which resulted in rapid pain resolution. He was diagnosed, thereafter, with malignant rheumatoid arthritis and methotrexate was administered. Postoperative angiography revealed that the occluded digital artery had become recanalized. Timely TS is therefore a treatment of choice for acute digital ischemia.

Hypothenar Hammer Syndrome in a Computer Programmer: CTA Diagnosis and Surgical and Endovascular Treatment

Finger ischemia due to embolic occlusion of digital arteries resulting from trauma to the palmar ulnar artery has been termed hypothenar hammer syndrome (HHS). In HHS, arterial thrombosis and/or aneurysm formation with embolization to the digital arteries causes symptoms of ischemia. We describe a patient in whom the initial diagnosis was made on multidetector computed tomographic angiography (CTA), as well as his endovascular and surgical management.

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

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.

The effect of α-adrenoceptor agonists and L-NMMA on cutaneous postocclusive reactive hyperemia

Postocclusive reactive hyperemia (PRH) is considered to be a locally mediated vascular reaction independent of sympathetic activity. However, experiments on animal vascular preparations have shown that α 2-adrenoceptor activity interferes with the production of endothelium-derived nitric oxide (NO) that has been found to play an important role in the PRH response. We attempted to elucidate the role of endothelium-derived NO in the cutaneous PRH response. Especially, we aimed to clarify the interference of the α-adrenoceptor activity with NO mechanism in cutaneous microcirculation. We studied the effect of intradermal microinjection of the NO synthase inhibitor L-NMMA alone, α 1-agonist phenylephrine alone, α 2-agonist clonidine alone and L-NMMA in combination with each α-agonist. The effect of the saline solution injection was used as a reference value. Laser-Doppler flux was monitored in 11 healthy volunteers before and after a 4-minute and an 8-minute occlusion of digital arteries. The application of L-NMMA significantly reduced resting LD-flux ( p < 0.05) only in combination with α 2-agonist but not α 1-agonist. The application of L-NMMA alone changed the time in which LD flux reached half of the preocclusive value during the PRH response (T/2) only after 4-minute ( p < 0.05) but not after an 8-minute occlusion. Phenylephrine (α 1-agonist) alone shortened ( p < 0.05), while clonidine (α 2-agonist) alone prolonged T/2 ( p < 0.05) of 8-minute PRH. The combined application of L-NMMA and clonidine abolished the effect of clonidine alone on 8-minute PRH. In contrast, the combination of L-NMMA and phenylephrine did not cause any change of the PRH response when compared to the injection of phenylephrine alone. Our finding is consistent with the hypothesis that α 2-adrenoceptor activity (in the condition of maximal agonist stimulation) could interfere with NO mechanisms in cutaneous microcirculation, probably by increasing NO production.

Long-Term Follow-Up of Hypothenar Hammer Syndrome

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.

The arterial complications of polycythaemia vera.

AbstractOf 200 patients referred for management of polycythaemia vera, 98 (49 per cent) had presented with vascular complications and 68 (34 per cent) of these involved arteries. Transient but recurrent cerebrovascular accidents and digital artery occlusions were the typical arterial complications. If polycythaemia was not promptly treated there was a risk of perimanent hemiplegia, monocular blindness, and severe ischaemia of the leg.Embolism may have accounted for some of the arterial complications. A possible source for emboli—a proximal mural thrombus—was demonstrated in all 5 patients who were examined with femoral arteriography and in 2 patients who underwent surgery. In selected cases thrombectomy may be indicated to prevent further embolism.

Autonomic nervous system and microvascular alterations in normotensives with a family history of hypertension

Autonomic nervous system and microvascular alterations at pre‐hypertensive stage of hypertension have still not been fully elucidated. We aimed at addressing central and local influences on microvascular reactivity at pre‐hypertensive stage of hypertension. To that end, we studied microvascular reactivity in 59 normotensives with a family history of hypertension and 46 controls. We measured laser‐Doppler flow on the finger nailfold skin in the resting condition, after an 8‐min occlusion of digital arteries and during local nitroglycerin application. Finger pressure, pulse and ECG were monitored by a Finapres device. Heart rate power spectral analysis was performed using Fast Fourier transformation. Baroreflex sensitivity was estimated by the sequence method. Normotensives with a family history of hypertension showed higher systolic pressure, decreased high‐frequency power of the heart rate variability spectrum and reduced baroreflex sensitivity in the resting condition as well as decreased fundamental frequency of laser‐Doppler flow oscillations during nitroglycerin application. We conclude that normotensives with a family history of hypertension exhibit altered sympathovagal balance with decreased parasympathetic activity at the cardiac level as well as increased myogenic microvascular reactivity.

Interferon-induced Raynaud's syndrome

Objective: To review the clinical features, diagnosis, treatment, and outcome of interferon-induced Raynaud's phenomenon. Methods: The medical literature was reviewed from1967 to November 2001 with the assistance of a MEDLINE search using the key words: Raynaud, Interferon, ischemia, thrombosis and necrosis. A qualitative review was performed after the articles were abstracted and the relevant information was summarized. Results: Twenty-four cases of interferon-induced Raynaud's phenomenon (including our patient) are described. Interpheron-alpha was the most common causative agent (14 cases). The symptoms appeared weeks to years after beginning treatment and varied from mild vasospasm to occlusion of digital arteries and tissue necrosis (14 cases), sometimes necessitating finger amputation (6 patients). Digital plethysmography, arteriography and capillaroscopy were valuable diagnostic tools. In 4 cases, cardiac, ophthalmic, or central nervous system drug-induced ischemia accompanied the peripheral Raynaud's phenomenon. Of the 15 cases with a documented outcome, withdrawal of the drug alone resulted in complete (6 patients) or partial (1 patient) recovery. In the others, supportive therapy was needed. The recovery period lasted from 2 weeks to 3 months. In 2 patients, continuation of treatment was possible. Conclusions: Raynaud's phenomenon and related complications must be recognized as possible side effects of interferon therapy. Early diagnosis and withdrawal of the drug may prevent unnecessary morbidity and disability. Semin Arthritis Rheum 32:157-162. Copyright 2002, Elsevier Science (USA). All rights reserved.

TREATMENT OF CHRONIC ISCHAEMIA OF A REPLANTED THUMB WITH ILOPROST

A 40-year-old man had chronic ischaemia of his replanted thumb. Angiography revealed occlusion of both digital arteries and weak collaterals. He was treated for 4 weeks with Iloprost which produced a definite and sustained improvement. As the digital arteries remained occluded, the beneficial effect of Iloprost was attributed to increased flow in the microcirculation and collaterals.

Microvascular Reactivity in Normotensive Subjects with a Familial Predisposition to Hypertension

Using the laser-Doppler method we measured blood flow on the nailfold skin to compare the reactivity of cutaneous microcirculation in three groups of normotensive subjects: 11 subjects with a familial predisposition to hypertension without a previous record of high blood pressure, 6 predisposed subjects with a previous record of high blood pressure, and 13 subjects with no predisposition to hypertension. The flow was measured after direct and indirect skin cooling and heating and during postocclusive reactive hyperemia (PRH) after a 10-min occlusion of digital arteries. The frequency of flow oscillations in the second part of the PRH was established. Heart rate spectral analysis was performed based on the monitoring of the peripheral pulse frequency by means of the finapres device. In comparison to the other two groups of subjects, the group with a predisposition and a previous record of high blood pressure displayed a larger surface area in the low frequency band (0.05 to 0.15 Hz) of the heart rate variability power spectrum (the Bonferroni test, P < 0.05). As compared to subjects without predisposition, both groups of predisposed subjects exhibited higher frequency of flow oscillations in the second part of the PRH (the Bonferroni test, P < 0.05). Our results indicate that there could be a change in cutaneous microvascular reactivity of local (most probably myogenic) origin even in normotensive subjects with a predisposition to hypertension, whereas in normotensives with a predisposition and a previous record of high blood pressure there could be also a different cutaneous microvascular reactivity of central (nonvascular) origin.

Thromboangiitis Obliterans (Buerger's Disease).

Thromboangiitis obliterans (TAO) is a devastating nonatherosclerotic disease that often leads to digit and limb loss as well as intractable ischemic rest pain. Patients with TAO are uniformly heavy users of tobacco. This disorder is characterized as a miscellaneous form of vasculitis affecting small- and medium-sized arteries and veins. TAO causes painful ischemic ulcers of the digits and unusually painful and inflammatory superficial thrombophlebitis. The key to early diagnosis of TAO is a high clinical index of suspicion in the appropriate patient scenario, exclusion of any other potential cause, abnormal results from an Allen's test, and arteriographic findings of segmental digital arterial occlusions with "corkscrew" collateral vessels. The primary and clearly most effective therapy for TAO is cessation of the use of all tobacco products, with avoidance of any environmental tobacco smoke inhalation. There has been recent enthusiasm for prostaglandin E therapy and the intramuscular injection of angiogenic growth factors. For patients in whom the disease is identified late or for those who are unable to discontinue cigarette smoking, however, a frequent result is multiple limb amputations.

Role of alpha-adrenoceptors in the cutaneous postocclusive reactive hyperaemia.

Laser-Doppler (LD) flow measurements reveal typical flow oscillations in the descending part of the cutaneous postocclusive reactive hyperaemia (PRH). The origin of these oscillations is still poorly understood. We tested the hypothesis that the high frequency (HF) components within the frequency band 0.06-0.2 Hz are due to the local myogenic mechanism, whereas the low frequency (LF) components within frequency band 0.01-0.05 Hz reflect sympathetic vasomotor activity. LD flow was monitored on fingertips of 11 healthy volunteers before and after an 8-minute occlusion of digital arteries. We studied the effect of intradermal microinjection (1 μl) of α-antagonists (prazosine, yohimbine) and α-agonists (phenilephrine, clonidine) on PRH oscillations. We analysed the magnitude of peak flow and its duration and performed spectral power analysis to obtain fundamental HF and LF frequencies (defined as components with the highest amplitude in the part of the respective frequency band). The results (mean ± SE) for each substance were compared to the control values obtained after microinjection (1 μl) of 0.9% NaCl. The fundamental HF significantly decreased from 0.11 ± 0.008 Hz after an injection of saline solution to 0.08 ± 0.006 Hz after an application of antagonists (p<0.05). The local application of α-antagonists did not abolished HF oscillations what suggests that activity of local sympathetic nervous system is not essential in generation of these oscillations. However, the significant decrease of fundamental frequency in HF band after application of α-antagonists supports the hypothesis of their local origin and could be explained by the effect on pacemaker myogenic mechanism.