Ulnar Artery Occlusion Research Articles

A case of Buerger's disease with vasculopathy and skin fibrosis requiring differential diagnosis from systemic sclerosis.

Buerger's disease is characterized by peripheral ischemia due to occlusion of small- and medium-sized arteries in the extremities. This report describes a case of Buerger's disease in a 51-year-old male who presented with findings resembling systemic sclerosis. The patient exhibited Raynaud's phenomenon in year X-3, which developed to skin hardening, nail avulsion, and ulceration of the right fingers in year X. Diagnostic testing showed positive microvasculopathy on nailfold videocapillaroscopy (NVC) and positive fibrosis on skin biopsy. Although the patient fulfilled the 2013 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for systemic sclerosis, several findings in this case were atypical for systemic sclerosis, including left-right asymmetry in finger involvement, nail loss, and negative autoantibody tests. Contrast-enhanced computed tomography showed poor perfusion of the right ulnar artery, and a heavy smoking history was established in the patient case. Therefore, based on Shionoya's criteria, he was diagnosed with a case of Buerger's disease confined to the upper extremity. Smoking cessation and vasodilator therapy resulted in the prompt resolution of ischemic symptoms, skin hardening, and ulcerations. Furthermore, NVC abnormalities improved, and ulnar artery occlusion showed reperfusion on repeat testing. The present case suggests that hypoxemia-driven microvasculopathy may contribute to vascular occlusion and skin fibrosis observed in this atypical presentation.

Serial dilation to enable ulnar artery access for endovascular neurointervention: Technical report and systematic review of the literature

BackgroundFor rare neuro-endovascular cases in which transfemoral access is not feasible and the palmar circulation is insufficient for radial artery access, ulnar artery access may be considered. Materials and methodsMechanical thrombectomy via ulnar artery access was performed to preserve the dominant radial artery. The ulnar artery was serial dilated to 7-French with microdilator. Angiography was performed using a diagnostic catheter. The sheath was exchanged for a guide catheter, and a triaxial system was inserted. A mechanical thrombectomy was performed. The systematic literature review included all studies pertaining to techniques for ulnar artery access for neurointervention in the last 20 years (2003–2023) published in the PubMed, Web of Science, and Embase databases. Results67-year-old male developed left MCA syndrome in the setting of an infected abdominal aortic endograft. A transfemoral approach was ruled out due to concern for crossing the infected endograft. Allen test and ultrasound demonstrated that the right radial artery was of adequate size for access, but the ulnar artery was insufficient to support the palmar arch. Mechanical thrombectomy resulted in TICI 3 reperfusion. Systematic review of the literature yielded 2 case series and 1 case report of transulnar neurovascular procedures. Access site complications were rare and included 3 access site hematomas and 1 ulnar artery occlusion. ConclusionWe report our technique of serial dilation of the ulnar artery for neuroendovascular procedures and provide a systematic review of the literature for complication avoidance in ulnar artery access.

TRANSULNAR TECHNIQUE AMONG PATIENTS UNDERGONE PERCUTANEOUS CORONARY INTERVENTIONS: A STUDY ON ASSOCIATED COMPLICATIONS

The objective of this observational study, conducted at the Department of Cardiology in LRH, Peshawar from June 2023 to December 2023, was to assess the complications associated with the transulnar technique in patients undergoing percutaneous coronary interventions (PCI) for ischemic heart disease. A total of 110 patients were included in this study. All patients underwent PCI with the transulnar technique, and complications were assessed post-procedure. The mean age of the patients was 58.75±7.05. The complications observed were minor bleeding in 20 patients (18.2%), ulnar artery occlusion in 9 patients (8.2%), hematoma in 6 patients (5.5%), and stroke in 2 patients (1.8%). The transulnar technique is an effective modality for patients undergoing PCI in terms of complications such as minor bleeding, ulnar artery occlusion, hematoma, and stroke.

Transulnar artery approach in STEMI - Best alternative to radial?

Abstract Background Transulnar artery approach is a valuable alternative wrist access site for percutaneous coronary interventions. Currently published data about using transulnar approach (TUA) in the STEMI setting are missing. Due to its similarities with transradial approach (TRA), TUA in STEMI (ST segment elevation myocardial infarction) procedures can help in decreasing access site bleeding and vascular complications without sacrificing procedural success. Purpose To assess the success and safety of Transulnar access in STEMI. Materials and Methods In the period from March 2011 until December 2021, 8013 consecutive STEMI patients underwent primary PCI (percutaneous coronary intervention) in our center. All consecutive patients with transulnar approach (TUA) were included in a single center prospective registry of effectiveness and safety. The primary outcome was procedural success through ulnar access. We also examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TUA. Results In this period, 172 STEMI patients (2.1%) underwent PPCI through transulnar approach. Mean age of patients was 60 ± 12 years with 27% females. All procedures were successfully performed through right TUA. There were no STEMI TUA cases with crossover to Transfemoral approach. In 150 patients (87%) TUA was the primary choice of puncture due to no palpable radial artery from previous radial artery occlusion. In 22 patients (12.7%) the reason for crossover from primary TRA to TUA were complex RA anomalies. Type 3 and 4 EASY Score hematoma was present in 4 patients (2.3%). 7% of patients had over 1 access site puncture. UA spasm was registered in 1.7%. Mean procedural time was 32±23 min and fluoroscopy time was 8.5±9.2 min. Ulnar artery anomalies were registered in 1% of patients. There were no ulnar artery occlusions detected at discharge. There were no clinical or ischemic hand complications seen during clinical follow up. Conclusion Transulnar approach is safe and feasible alternative wrist access in the STEMI setting and can further decrease TFA crossover.

Transradial or Transulnar Long Sheath Access to the Brachial Artery Allows for Neuroendovascular Procedures in Patients with Radial or Ulnar Artery Occlusion

Transradial access is an important tool for many neuroendovascular procedures. Occlusion of the radial or ulnar artery is not uncommon after transradial or transulnar access and can present a challenge for patients requiring repeat angiography. Between March 2022 and June 2023, patients undergoing transradial or transulnar angiography who were found to have a radial artery occlusion or ulnar artery occlusion were identified. Repeat catheterization of the occluded artery was attempted using a 21-gauge single wall puncture needle and a 0.021-inch wire to traverse the occlusion and insert a 23-cm sheath into the brachial artery. A total of 25 patients undergoing 26 angiograms during the study period were found to have a radial artery occlusion or ulnar artery occlusion. Successful repeat catheterization of the occluded artery was achieved in 21 of 26 cases (80.7%). Outer diameter sheath size ranged from 5 Fr (0.0655 inch) to 8 Fr (0.1048 inch). No access complications were encountered. Number of prior angiograms, time since prior angiogram, and prior angiogram procedure time were associated with lower likelihood of successful access. Transradial or transulnar neuroangiography through an occluded radial or ulnar artery is safe and feasible by traversing the occlusion into the brachial artery with a 23-cm sheath. Repeat catheterization is most successful in patients with an arterial occlusion <6 months old. This technique is important in patients who have limited options for arterial access, avoiding access site complications inherent in transfemoral access, and in patients who specifically require radial or ulnar artery access.

Distal radial artery access for the treatment of complications after ulnar artery catheterization

Objective: to study the effectiveness of the distal radial artery access in the treatment of complications after ulnar artery catheterization. Material and methods. We analyze the outcomes of 1558 catheterizations of the ulnar arteries. Less than 1% of local hemorrhagic complications and 1.5% of post-catheterization occlusions of the ulnar artery were revealed after ulnar artery catheterization, Results. One half of the patients with hemorrhagic complications after ulnar artery catheterization underwent conservative treatment (mechanical compression of the site of complication), the rest of patients underwent surgical treatment. Positive effect was achieved in all patients who underwent endovascular treatment for post-catheterization hemorrhagic complications. In 50% of cases, recanalization of post-catheterization ulnar artery occlusion via the distal radial access was effective. In 1 patient after recanalization of post-catheterization ulnar artery occlusion using the distal radial artery access, the occlusion of radial artery in wrist segment occurred, with preserved blood flow in radial artery of the forearm. Conclusion. Distal radial artery access for correction of post-catheterization complications in ulnar artery is a feasible and safe method. Keywords: distal radial access, ulnar artery, radial artery, occlusion

Peripheral Macrovascular Involvement in Systemic Sclerosis: A Cohort Study by Color and Spectral Doppler Ultrasonography.

Systemic sclerosis (SSc) is a disease characterized by diffuse sclerosis of skin and organs and small vessel vasculopathy. Despite it, large vessels can also be involved with ulnar artery vasculopathy, revealing as a more frequent feature of SSc. The aim of this paper is to assess the macrovascular involvement of SSc patients through an ultrasound (US) evaluation of radial and ulnar arteries. Radial and ulnar resistance indices (RIs) and peak systolic velocity (PV) (cm/s) together with clinical features of SSc patients were evaluated. Raynaud phenomenon (RP) and healthy control (HC) groups were used for comparison. Forty-three SSc patients were evaluated. Twelve patients (28%) had ulnar artery occlusions (UAOs). In nine cases (75%), UAOs were bilateral. A high UAO prevalence (42%) was found in SSc patients with late nailfold-video-capillaroscopy (NVC) pattern (p = 0.0264). Patients with UAOs had digital ulcers (DUs) in 10 cases (83.3%). Radial and ulnar PVs were lower in SSc and RP patients than the HC group. Radial and ulnar RIs were higher in SSc and RP patients than the HC group. A decision tree analysis led to the classification of 70% of SSc patients with an ulnar RI > 0.82 and ulnar PV > 2.8 cm/s. The most influential variables on UAO development were interstitial lung disease (ILD) (p = 0.002) and NVC pattern (p = 0.002). A positive correlation was shown between modified Rodnan skin score (mRSS) and ILD (p = 0.283; r = 0.033), mRSS and DU (r = 0.344; p = 0.012) and DU and ILD (r = 0.303; p = 0.024). Male sex was associated with increased UAO frequency (p = 0.042). UAO is a peculiar feature of severe SSc present in 28% of the cases, particularly associated with the presence of ILD and late NVC pattern. In 75% of the cases, UAOs are bilateral. DUs are very frequent in patients with UAOs (83%). The RI evaluated by US could be useful to distinguish SSc from HC patients. US could be a useful tool for assessing high-risk DU development in patients.

Ultrasound Classification of Finger Pulp Blood Flow in Patients With Systemic Sclerosis: A Pilot Study.

To define a semiquantitative classification of finger pulp blood flow (FPBF) and to evaluate whether this classification could be used to assess FPBF in healthy controls and in systemic sclerosis (SSc) patients. Thirty controls and 86 SSc patients were consecutively included. A classification of FPBF including 5 grades (from grade 0 [no signal] to 4 [signal detected on the entire finger pulp, including the subepidermal vascular network]) was evaluated. This classification was explored in basal conditions and after hand baths in hot and cold water in controls. Its relevance was also assessed at room temperature in SSc patients. In controls, power Doppler ultrasonography (PDUS) of FPBF was improved after hot challenge (P=0.024), whereas cold challenge decreased FPBF (P=0.001). FPBF correlated with the vasodilation status assessed by the resistivity index of radial arteries (Spearman's correlation coefficient=-0.50, P=0.0049). Grade 0 was more frequent in SSc patients than in controls (22.1% versus 3.3%; P < 0.05). In SSc patients, grade 0 was associated with severity markers of the digital vasculopathy such as digital ulcers (DUs) (current or past) (P < 0.05) or ulnar artery occlusion (P < 0.05). On the other hand, DUs were less frequent in patients with grade 4 (P < 0.05). A pathologic threshold of <2 (grade 0 or 1) was significantly associated with DUs (odds ratio 6.67 [95% confidence interval 2.31-19.21], P < 0.0001). PDUS allowed a semiquantitative evaluation of FBPF in SSc patients and controls. Further studies are warranted to validate these results in independent SSc populations and to compare PDUS to existing tools assessing digital blood flow.

Complications Associated with Transulnar Approach in Patients undergoing Percutaneous Coronary Interventions

Aim: To examine the prevalence of complications related with transulnar approach in patients undergoing elective percutaneous coronary interventions. Study Design: Cross-sectional/observational study. Place &amp; Duration: The study was conducted at cardiology department of Cat A Hospital Batkhela and Fauji Foundation Hospital Peshawar for six months duration from January 2020 to December 2020. Methods: One hundred and eighteen patients of both genders with ages 20 to 75 years who underwent percutaneous coronary interventions were included. Patients’ detailed demographics including age, sex, BMI and com-morbidities were recorded after taking informed written consent from all the patients. All the patients had percutaneous coronary procedure through transulnar approach and periprocedural complications were examined. Data was analyzed using SPSS 24.0. Results: Out of 118 patients 85 (72.03%) were males and 33 (27.97%) were females with mean age of 55.74±11.71 years. Mean BMI was 28.09±7.33 kg/m2. Hypertension was the most common morbidity found in 63 (53.4%) patients followed by diabetes mellitus and smoking. Minor bleeding was the commonest complication found in 28 (23.7%) patients followed by ulnar artery occlusion, excessive bleeding, ulnar nerve injury and hematoma in 10 (8.5%), 8 (6.8%), 6 (5.08%) and 2 (2.5%) patients respectively. Conclusion: It is concluded that transulnar approach for coronary interventions is safe and effective with fewer rate of complications. Keywords: Coronary Intervention, Angiography, Transulnar Approach, Complications.

Is Hyperspectral Imaging Suitable for Assessing Collateral Circulation Prior Radial Forearm Free Flap Harvesting? Comparison of Hyperspectral Imaging and Conventional Allen's Test.

(1) Background: This cross-sectional study aims to compare a new and non-invasive approach using hyperspectral imaging (HSI) with the conventional modified Allen’s test (MAT) for the assessment of collateral perfusion prior to radial forearm free flap harvest in healthy adults. (2) HSI of the right hand of 114 patients was recorded. Here, three recordings were carried out: (I) basic status (perfusion), (II) after occlusion of ulnar and radial artery (occlusion) and (III) after releasing the ulnar artery (reperfusion). At all recordings, tissue oxygenation/superficial perfusion (StO2 (0–100%); 0–1 mm depth), tissue hemoglobin index (THI (0–100)) and near infrared perfusion index/deep perfusion (NIR (0–100); 0–4 mm depth) were assessed. A modified Allen’s test (control) was conducted and compared with the HSI-results. (3) Results: Statistically significant differences between perfusion (I) and artery occlusion (II) and between artery occlusion (II) and reperfusion (III) could be observed within the population with a non-pathological MAT (each <0.001). Significant correlations were observed for the difference between perfusion and reperfusion in THI and the height of the MAT (p < 0.05). Within the population with a MAT >8 s, an impairment in reperfusion was shown (each p < 0.05) and the difference between perfusion and reperfusion exhibited a strong correlation to the height of the MAT (each p < 0.01). (4) Conclusions: The results indicate a reliable differentiation between perfusion and occlusion by HSI. Therefore, HSI could be a useful tool for verification of the correct performance of the MAT as well as to confirm the final diagnosis, as it provides an objective, reproducible method whose results strongly correlate with those obtained by MAT. What is more, it can be easily applied by non-medical personnel.

Sonographic Evaluation of a Perpetual Penetrating Retained Wood Splinter, Ulnar Artery Occlusion, and Soft Tissue Swelling in the Left Arm CME credit June 2021

Sonographic Evaluation of a Perpetual Penetrating Retained Wood Splinter, Ulnar Artery Occlusion, and Soft Tissue Swelling in the Left Arm CME credit June 2021

Ipsilateral transulnar artery approach catheterizations after failure of the radial approach-Are two sheaths in the same arm safe?

To assess the safety and feasibility of ipsilateral transulnar access (TUA) after failure of radial access (TRA), with two sheaths placed in the radial and ulnar arteries (RA and UA) in the same arm. All consecutive patients with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until September 2020 were included in the study. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TRA. Patients were assessed by duplex ultrasound post-procedure (at an average of 56 ± 31 months) and followed clinically (functional and pain assessment). In this period, out of 51,866 patients 112 (0.2%) had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 65 ± 11 years with 44% females. Cause for crossover to ipsilateral TUA was inability to cross a RA anomaly in 107 (95%) patients, mostly due to the presence of a "360°" RA loop in 88 patients. Type 3 and 4 EASY Score hematoma was present in 3 patients (2.6%). Six (5.3%) of the patients had new ipsilateral radial artery occlusion noted on duplex on follow up. There were no ulnar artery occlusions detected. There were no clinical or ischemic hand complications seen during a median 4.3 years of follow up. Ipsilateral transulnar artery access following failed radial artery access crossing is safe and successful for coronary angiography and intervention with low rates of complications.

Ultrasound evaluation of the hands and wrists in patients with systemic sclerosis: Osteophytosis is a major contributor to tender joints

ObjectiveTo evaluate the prevalence and clinical associations of ultrasound (US) findings of inflammatory arthritis and joint and soft tissue pathology in patients with systemic sclerosis (SSc). MethodsThe hands and wrists of 43 SSc patients and 35 age-balanced controls were evaluated by clinical exam and musculoskeletal US. Synovial and tenosynovial pathology were assessed using semi-quantitative Gray Scale (GS) and Power Doppler (PD) scoring. US evaluation for osteophytes, erosions, ulnar artery occlusion, and median nerve cross-sectional areas was performed. Tender joints (TJ), swollen joints (SJ), modified Rodnan skin score (mRSS), digital ulcers, contractures, and calcinosis were evaluated. Concordance between US and physical exam findings at each joint region were assessed, and associations between their severity were analyzed. ResultsTJs and SJs were present in 44.2% and 62.8% of SSc patients, respectively. Inflammatory arthritis, defined as having both GS>0 and PD>0, was observed in 18.6% of SSc patients and no controls. There was a high concordance by joint region between GS synovial hypertrophy and osteophytes (κ=0.88) as well as TJs (κ=0.72). SSc patients had more osteophytes compared to controls (48.8% vs 22.9%, p = 0.018) as well as higher osteophyte severity (p = 0.033). ConclusionsDespite a high percentage of tender and swollen joints, less than 20% of SSc patients met criteria for inflammatory arthritis on US. The high concordance of osteophytes with GS synovial hypertrophy and tender joints suggest that osteophytosis may be a significant contributor to joint pain in SSc patients.

Sonographic Evaluation of a Perpetual Penetrating Retained Wood Splinter, Ulnar Artery Occlusion, and Soft Tissue Swelling in the Left Arm

Penetrating foreign bodies are frequently encountered, most commonly wood, glass, or metal slivers. Retained foreign bodies are often overlooked on initial examination and only 15% of wooden foreign bodies are detected by radiographic visualization such as radiography (X-ray), computerized tomography (CT), and magnetic resonance imaging (MRI). Soft tissue infection is the most common complication of a penetrating foreign body. This case report describes a 63-year-old man who was caught under a falling tree limb. His left forearm was speared by a large branch causing an open wound. Ten years later, the patient presented to the emergency department with pain, edema, and erythema. A left arm venous duplex was performed using dynamic B-mode imaging with pulsed Doppler to evaluate the venous system for thrombosis and a palpable mass. Sonography revealed a “perpetual” retained linear foreign body encased in a fluid collection and a distal ulnar artery occlusion with reconstitution of flow at the level of the wrist. Surgical correlation confirmed the presence, size, and location of the foreign body and associated fluid and debris. The foreign body, a wood splinter, was surgically removed without complications.

Impact of the Use of a Larger Forearm Artery on the Efficacy and Safety of Transradial and Transulnar Access: A Randomized Trial with Preprocedural Ultrasonography.

(1) Background: We aimed to assess the impact of the selection of a larger radial or ulnar artery on the efficacy of access and vascular complications, based on preprocedural ultrasonographic examination. (2) Methods: This prospective, randomized trial included patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI). Patients were randomized into either a larger ulnar artery (UA) or radial artery (RA) group or smaller UA/RA group. The primary endpoint was successful CAG/PCI without crossover to another artery. The secondary endpoints were incidences of radial or ulnar artery occlusion (RAO/UAO) at the 24 h and 30 day follow-up. (3) Results: Between 2017 and 2018, 200 patients (107 men, mean age 68 ± 8 years) were enrolled. The success of CAG/PCI via the access site was 98% and 83% (p < 0.001) in the larger UA/RA group and smaller UA/RA group, respectively. The independent factor for CAG/PCI success was the larger artery (OR 9.8, 95%CI 2.11–45.5; p < 0.005). The larger UA/RA was superior, with RAO/UAO at 24 h: OR 0.07, 95%CI 0.09–0.61; p < 0.016; and RAO/UAO at 30 days: OR 0.25, 95%CI 0.05–0.12; p < 0.001. (4) Conclusions: Larger artery access was shown to be more efficient and safer than recessive forearm artery access.

Safety and feasibility of ulnar artery access for neuroangiography and neurointervention: a case series

BackgroundRadial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a...

Transulnar Catheterization in Patients with Failed Ipsilateral Transradial Access: Novel TR Band Modification for Dual-Site Hemostasis

ObjectivesThis study investigated the feasibility and safety of transulnar access (TUA) and efficacy of novel TR band modification for dual site hemostasis in patients with failed ipsilateral transradial approach. BackgroundFailed transradial access requires cross over to alternative access site. There is paucity of data on feasibility and safety of ipsilateral TUA due to concern of potential risk of hand ischemia. MethodsWe retrospectively reviewed ten patients who underwent coronary angiography and intervention via ulnar artery in the setting of failed ipsilateral transradial access. Patent hemostasis for both ulnar and radial arteries was achieved with novel modification of the TR band to compress both arteries at the same level of puncture sites. ResultsTUA after failed ipsilateral transradial access was successful in all ten cases. All patients were followed within 7 days and there were no adverse complications such as ulnar artery occlusion, nerve injury, or hand ischemia. ConclusionTUA maybe a safe and viable option when cross over is necessary from failed ipsilateral transradial access. Modification of the TR band for both radial and ulnar access site can achieve patent hemostasis effectively at the level of both puncture sites.

The transulnar approach in the patients with ipsilateral radial artery occlusion.

BACKGROUNDTransulnar approach (TUA) has been classified as an appropriate surrogate for the transradial approach (TRA), but the safety of TUA in the presence of ipsilateral radial artery occlusion (RAO) is not well studied. In this article, we aimed to assess the feasibility and occurrence of complications of this approach in Iranian individuals with ipsilateral RAO.METHODSIn this prospective double-center study, a total number of 70 participants from July 2017 to November 2018 with coexisting ipsilateral RAO due to prior RA angiography, severe arterial spasm, prominent vascular anomalies, or arterial harvesting for hemodialysis or graft procedures were enrolled and underwent TUA. Incidence of probable complications including pain, hematoma, arteriovenous fistula (AVF), pseudoaneurysm formation, any adverse events requiring immediate vascular surgery, life-threatening hand ischemia, infection, ulnar nerve palsy, major adverse cardiac events (MACE) including death, myocardial infarction (MI), or stroke plus ulnar artery (UA) obstruction and narrowing was evaluated both before discharge time and one month afterward.RESULTSThe mean age of the study population was 68.2 ± 12.8 years [men number: 41 (58.5%)]. Our success rate was 98.6% and 37.1% of subjects underwent further coronary intervention. No aforementioned adverse outcomes were reported in any individual except for pain (11.4%) and minor hematoma (grade I) (5.7%) as well as MACE (1.4%). Follow-up assessment revealed asymptomatic UA occlusion (UAO) and severe narrowing in 2.8% and 1.4% of participants, respectively.CONCLUSIONOur outcomes suggested that due to high safety and low complication rates, TUA could be tried safely in patients with concurrent ipsilateral RAO. Other appropriate cohort studies are required for assessing the incidence of TUA complications.

Upper extremity arterial endovascular interventions for symptomatic vascular access-induced steal syndrome

BackgroundCritical hand ischemia owing to vascular access-induced steal syndrome (VASS) continues to be a significant problem. The aim of this study was to examine the outcomes of arterial endovascular interventions in the upper extremity of patients presenting with VASS. MethodsA database of patients presenting with documented VASS between 2006 and 2016 was retrospectively queried. Patients who underwent isolated endovascular intervention in the upper extremity were analyzed. ResultsNinety-eight patients (66% female; average age 65 years) presented with VASS: 28 presented with upper arm atherosclerotic disease above the arteriovenous (AV) anastomosis (above elbow) and the remaining 70 patients with below AV anastomotic atherosclerotic disease at the elbow (below elbow). Sixty-three percent of the entire patient cohort (N = 65) presented with rest pain and the remainder (n = 33 [34%]) with minor digital ulceration. Of those with upper arm disease above the AV anastomosis, one-third of patients had subclavian occlusive disease and two-thirds had brachial artery occlusive disease. Patients with subclavian disease underwent stent placement, and patients with brachial artery disease underwent balloon angioplasty. Technical success was 100% (n = 28). Ninety-one percent of these patients (n = 25) had symptomatic success at 30 days and the remainder (n = 3) required proximalization of the access. Of those with below AV anastomosis at the elbow disease, all had disease in the forearm vessels with 42% (n = 29) having either the ulnar or radial artery occlusion. Balloon angioplasty was performed in one vessel in 55% (n = 38) and in two vessels in 45% (n = 32) of patients. Technical success was 79% (n = 81 of 102 vessels) with 51% of the patients (n = 36) having symptomatic success at 30 days; of those who remained symptomatic, 80% (n = 27) required proximalization of the access and 20% (n = 7) required ligation. The major adverse cardiovascular event rate for the entire patient cohort was 4% (n = 4). The 30-day complications for the entire patient cohort included continued steal (38%; all resolved with secondary procedures), thrombosis (3%; all forearm vessels treated for occlusion), bleeding (0%), infection (0%), and mortality (1%). Primary clinical success defined as the relief of distal ischemic symptoms and the preservation of a functional access site for dialysis showed rates of 42 ± 9% (mean ± standard error of the mean) and 0 ± 0% at 5 years (above and below elbow groups, respectively). ConclusionsUpper extremity interventions for VASS owing to above elbow disease are associated with a high rate of success, whereas interventions for below elbow disease have a poor clinical success with more patients requiring secondary procedures and low long-term survival for the access site. Male patients presenting with rest pain, larger forearm vessels (approximately 3 mm), short occlusive lesions (<100 mm), two-vessel runoff, and an intact palmer arch are good candidates for below elbow interventions.

Ulnar Artery Occlusion and Severity Markers of Vasculopathy in Systemic Sclerosis: A Multicenter Cross-Sectional Study.

To evaluate the association of ulnar artery occlusion (UAO) assessed using Doppler ultrasound (DUS) with the severity markers of systemic sclerosis (SSc). Two hundred four unselected patients fulfilling the American College of Rheumatology/European League Against Rheumatism 2013 classification criteria for SSc were included in this cross-sectional multicenter study. All patients underwent bilateral hand DUS to evaluate the presence of UAO and clinical/paraclinical visceral evaluation according to current guidelines. Univariable and multivariable ordinal regression models were applied, grading the severity of UAO as "no UAO," "only one UAO," and "UAO on both hands," and assessing its association with clinical features of SSc. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. UAO was found in 76 patients (37.3%) and was bilateral in 49 patients (24%). UAO as an ordinal event was significantly associated with disease duration, history of fingertip ulcers, telangiectasia, higher modified Rodnanskinthickness score (MRSS), worse diffusing capacity for carbon monoxide (DLco) values, higher tricuspid jet velocity, late capillaroscopic pattern, and positivity for anticentromere antibodies (ACAs) (univariable analysis). In the adjusted multivariable ordinal model, UAO was less frequent in women (OR 0.35 [95% CI 0.15-0.83], P = 0.017) and in patients receiving steroids (OR 0.24 [95% CI 0.09-0.62], P = 0.0034). In multivariable analyses, significant association with UAO was retained for history of fingertip ulcers (OR 2.55 [95% CI 1.24-5.21], P = 0.011), higher MRSS (OR 1.65 [95% CI 1.06-2.56], P =0.025), lower DLco values (OR 0.85 [95% CI 0.78-0.94], P = 0.0015), and ACA positivity (OR 2.89 [95% CI 1.36-6.11], P = 0.0056). UAO may represent a relevant severity marker of vasculopathy in SSc. Its predictive value for the onset of severe vascular manifestations such as pulmonary arterial hypertension, and its association with mortality, remain to be determined in longitudinal studies.