Treatment of Critical Hand Ischemia with Atherectomy and Balloon Angioplasty in a Hemodialysis Patient

Abdul Bah ro, MD, FACC, FSCAI; Connie Williams , AGACNP-BC; and William C. Li neaw eaver, MD, FACS

A patient with critical arteriosclerotic ischemia of his left upper extremity was treated with angiographic atherectomy and balloon angioplasty, resulting in restoration of circulation to his hand, resolution of pain, restoration of function, and healing of ischemic finger necrosis.

Keywords: upper extremity ischemia; angiography; angioplasty

A common problem plaguing diabetic and end-stage renal disease patients is the development of calcified peripheral artery disease of the forearm and hand. Severe pain and critical hand ischemia can develop, leading to amputations. Unfortunately, only sparse data are available for therapeutic treatments of calcified lesions distal to the elbow. 1-4 Studies have proven that heavily calcified lesions are effectively treated with atherectomy followed by balloon angioplasty below the knee, but below the elbow lesions are often excluded from therapeutic consideration because of small vessel size. 5-6 We present a case of upper extremity critical ischemia treated with atherectomy and angioplasty, illustrating the utility of this strategy in the forearm and hand.

The patient was a 69-year-old man with a past medical history of hypertension, diabetes mellitus, hyperlipidemia, and end-stage renal disease on hemodialysis. He was referred from his dialysis center for resting ischemia to the left hand. He had an arteriovenous fistula for dialysis in his proximal left arm. He developed severe pain, discoloration, and necrotic areas to the tips of his fingers. He was previously admitted to another local hospital for 12days and treated with anticoagulation with no improvement in his ischemic symptoms. His pain progressively worsened, and necrotic areas were increasing in size. The pain was so severe he was unable to move his fingers (Figure 1). He was then referred to our facility.

An arterial Doppler study review of the left upper extremity showed severe peripheral arterial disease, and the patient was scheduled for angiography. The images revealed severe disease in the proximal and mid-left radial artery with an occluded segment just proximal to the wrist, along with an occluded ulnar artery distal to the wrist (Figure 2). The recommendation was to proceed with endovascular intervention to the radial artery.

Resting Ischemic Changes to the Left Hand

Guidewire Crossing Occluded Distal Segment of Radial Artery

Balloon Angioplasty Left Radial Artery

A 5-French sheath was used to cannulate the right femoral artery. A 5-French manufactured Bernstein catheter and an Advantage wire were used to advance the catheter into the proximal brachial artery. Selective angiography was then performed. To perform intervention, a long NaviCross catheter was advanced over the Advantage wire to the distal brachial artery. A long 6-French Destination sheath was advanced to the midbrachial artery. Heparin and Aggrastat were given intravenously. Using a PT Choice guidewire and a Seeker catheter, the occluded segment in the distal radial artery was crossed (Figure 3). The wire was then exchanged to a Viper wire. Atherectomy was performed using 1.25 solid crown followed by balloon angioplasty using 2.0 × 40mm in the distal segment of the radial artery. A 2.5 × 150mm balloon was utilized in the proximal and midportion of the vessel. Each balloon was inflated between 4–6

atmospheres for 2–3minutes (Figure 4). The final angiogram revealed excellent flow through the treated segment (Figure 5).

The day after the procedure, the patient was able to move his fingers, and the pain was completely resolved. Color had returned to his fingertips, and he was discharged home that day.

The patient returned to the clinic 6weeks after the procedure. The ischemic ulcerations had healed entirely. His pain had resolved, allowing full mobility of his hand. Coloration had returned to normal (Figure 6). The outcome was successful in restoring blood flow to his fingertips, allowing proper healing, and preventing amputation.

Improvement of Hand Soft Tissues

When performing endovascular procedures, it is important to maintain activated clotting time at or over 250seconds. Gentle wire manipulation should be utilized when working with heavily calcified lesions. A small Diamondback crown is appropriate for atherectomy. Vasodilators such as Verapamil may be administered through the exchange catheters. The angioplasty balloon should be the same size as the diameter of the vessel. Long and low inflations are recommended initially with progression to a smaller balloon with higher inflation pressures for resistant lesions.

This case study shows that upper arm critical limb ischemia can be effectively treated with endovascular techniques such as atherectomy.

Upper extremity revascularization is increasingly recognized as a valuable intervention for upper extremity ischemia. Such ischemia can be caused by arteriosclerosis or a variety of other processes including emboli, thrombi, arteritis (Buerger’s disease), connective tissue diseases, and chronic vasospasm (Raynaud’s disease). 7

Arteriography is a definitive study for evaluation for treatment of upper extremity ischemia. For arteriosclerotic ischemia, arteriography can include revascularization procedures such as the one described in this case report. In cases where bypass grafting, sympathectomy, and venous arterialization are considered, arteriography can provide a map for the planning of such procedures. 7-10 n

Conflict of Interest Disclosures: The authors have nothing to disclose.

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Interventional Cardiology, Merit Health Central Hospital (Bahro, Williams). Medical Director, JMS Burn and Reconstruction Center at Merit Health Central Hospital (Lineaweaver).

Corresponding Author: Abdul Bahro, M.D., F.A.C.C., F.S.C.A.I.; Interventional Cardiology Merit Health Central Hospital, 1850 Chadwick Dr., Jackson, MS, 39204. Ph: (601)376 1394. Fax: (601)376 1684 (abdulbahro@hotmail.com).