Technical outcomes of below-the-elbow revascularization for upper extremity critical limb ischemia

Introduction

Critical hand ischemia (CHI) is an uncommon yet disabling condition that leads to functional impairment. ¹ The frequency of symptomatic hand ischemia is 40 times less than the incidence of lower limb ischemia. Initial evaluation of etiologies and determination of therapeutic strategies remains challenging. End-stage renal disease (ESRD) and diabetes mellitus are considered the most common risk factors for CHI.^2-4 For above-the-elbow artery disease, percutaneous angioplasty is considered as the first-line therapy. ¹ However, only a few studies in the literature discuss the treatment of below-the-elbow arteries (BTEA). This study aims to demonstrate that angioplasty is a technically feasible and safe method to manage critical stenosis at the BTEA.

Methods

Patients with hand ischemia requiring upper extremity angiograms were identified between January 2013 and January 2017. The upper extremity arteriograms and interventions were retrospectively reviewed. The data collection included patient’s clinical presentation, comorbidities, angiographic findings, and clinic follow-up information through a retrospective chart review. Patients with a history of thoracic outlet syndrome, vasculitis, and prior upper extremity radiation treatment were excluded. Within the procedural data, treated vessel, stenosis characteristics, and technical outcomes were assessed. The clinical presentation and amputation data were recorded. Informed consent was obtained from all patients before the procedure. The institutional review board approved this study.

The angiograms and interventions were performed under conscious sedation through a transfemoral approach. A 6-French (F) introducer sheath (Cook Medical, Indiana, USA) was used to access the aorta. Through this access, upper extremity arteries were selected with a 5-F catheter. Then, an angiogram was obtained to delineate vascular anatomy and identify the arterial lesions. After this diagnostic portion, the critical stenoses or occlusions in the BTEA were crossed with a Quick Cross catheter (Boston Scientific Corporation, Minnesota, USA) and a 0.014-inch hydrophilic tip guidewire. For angioplasty, the hydrophilic guidewire was exchanged for a Spartacore guidewire (Abbott Vascular, Santa Clara, California, USA), and angioplasty was performed with small-profile balloons, diameter ranging between 1.5 mm and 3 mm. Representative images are shown in Figure 1.OPEN IN VIEWER

Patients with visible ulcerations continued wound care management with referring surgical service, and follow-up information was obtained through clinic visit records. Technical success was defined as successful wire crossing to the palmar arch with a final residual stenosis diameter of <30%. Stenosis was graded as mild, moderate, and severe for the degree of vessel stenosis 30–50%, 50–70%, >70%, respectively.

Results

A total of seven patients (3 female; 4 male, 59.7 ± 8.7 years) underwent BTEA revascularization; four presented with non-healing ulcers, two presented with gangrene, and one presented with rest pain. All patients had a history of ESRD, and six patients had ipsilateral arteriovenous fistula or graft (85.5%, n = 6/7). Two of these patients had history of steal syndrome which did not require surgical revision after BTEA. Three out of seven patients had history of lower extremity revascularization (42.8%). The average follow-up duration was 9 months, ranging between two and 26 months. One patient expired due to existing respiratory disease 30 days after the intervention; one patient underwent digital amputation 8 months after the intervention. The remainder patients showed improved wound healing and resolved rest pain.

Twelve vessels were treated in nine extremities. In two limbs, 3 vessels were treated (22.2%, n = 2/9); in five limbs, 2 vessels were treated (55.55%, n = 5/9); and in one limb, two limbs, one vessel was treated (22.2%, n = 2/9). The average lesion length was 147.5 mm (+/− 97.9 mm).

Twelve arteries were intervened depending on the patients' clinical symptoms. Seven (58.3%, n = 7/12) procedures were performed on radial arteries, four (33.3%, n = 4/12) on ulnar arteries, and one (8.3%, n = 1/12) on the interosseous artery. Of the treated lesions, one (8.3%) was focal stenosis, nine (75%) were multi-focal stenoses, and two (16.6%) were chronic total occlusions (CTO). The mean PTA balloon diameter was 2.23 mm (±0.33). In two vessels, recanalization was unsuccessful due to multi-focal high-grade stenosis (16.6% n = 2/12). The technical success rate was 83.3% (n = 10/12).

Discussion

Upper extremity critical limb ischemia (CLI) is an uncommon entity seen 40 times less often than lower extremity CLI. Recent data suggest that BTEA stenosis is more common in dialysis patients due to the surgical creation of an AVF, whether anatomic or inflammatory.^5-6 The typical challenge is the loss of follow-up due to extensive comorbidities. This challenge also may explain the delayed diagnosis and the limited number of CHI studies in the literature.^7,8

In the present study, all patients had a history of ESRD. Other etiologies of CHI include diabetes, trauma, iatrogenic causes, and occasionally vasculitis. ⁹ Patients with CHI generally develop ulcerations, tissue necrosis, and gangrene of the fingers, which require revascularization. To avoid amputation and improve patient quality of life, percutaneous intervention remains the preferred first-line therapy for arterial occlusions of the upper extremity. ¹¹ Overall, this study demonstrates a high technical success rate (83.5%), which is similar to that in previously reported studies. Most patients (71.4%) have lower extremity peripheral arterial disease. These findings reinforce the idea that BTE vessel disease is an extreme expression of advanced atherosclerotic disease. Moreover, many comorbidities and challenges in diagnosis explain the limited number of CHI studies and the high mortality rate during follow-up. Ruzsa et al. ¹² demonstrated a high major adverse event rate of 27% at 1-year follow-up, including a composite of death, myocardial infarction, stroke, major upper arm amputation, and repeated revascularization required arterial bypass graft surgery. Critical hand ischemia poses a unique case where most identified patients have ESRD with an AVF that is often assumed to be malfunctioning due to arterial steal or diabetic neuropathy. It often leads to misdiagnosis and mistreatment. ⁴ Multiple case studies have demonstrated that as many as 61% of patients have undergone a banding procedure for arterial steal without previous arteriography, with most experiencing 6-month patency of 94%, inferring some degree of secondary arterial stenosis.

Although most cases were performed similarly, variations in access and techniques exist to ensure increased success in canalization and treatment of the target lesion. One common method utilized includes the “radial to ulnar artery loop technique” for occlusion of the distal ulnar artery, where a 0.0014-in guidewire was advanced to the radial artery and passed through the superficial palmar arch together with the balloon catheter, then the distal part of the occluded ulnar artery was engaged and retrograde recanalization with balloon angioplasty was performed. ¹¹ Despite the variations, critical principles in CHI and peripheral arterial interventions remain the same, including dedicated below-the-knee balloons using a long inflation time and the need for subintimal penetration.^10-13

The study has several limitations, including its retrospective nature, a small sample size, and the fact that it was conducted at a single institution. Another limiting factor is procedures being performed by different interventionalists.

Conclusion

Despite the challenges in detecting CHI, BTE vessel disease is becoming increasingly frequent, given patients' prolonged survival with ESRD. With an increasing demand for recanalization of the upper limb, interventionalists will continue to require guidance and studies demonstrating the technical feasibility of performing BTE interventions to improve the hand salvage rate.