Surgical treatment of chronic hand ischemia: a systematic review and case series
David L. Colen, MD1, Thibaudeau Stephanie, MD2, Oded Ben-Amotz, MD2, Martin Carney, BA2, Patrick A. Gerety, MD3; L. Scott Levin, MD2
1University of Pennsylvania, Philadelphia, PA; 2McGill University, Montreal, QC, Canada; 3Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN
Background: Chronic ischemia of the hand can cause intractable pain, cold intolerance, and digital necrosis and is often a significant challenge for hand surgeons. In this study we aim to systematically review the literature regarding surgical treatment of chronic hand ischemia and present our experience with various techniques in order to formulate an algorithmic approach to this difficult problem.
Methods: A systematic search of the literature published since 1990 in the PubMed/MEDLINE database was performed using keywords. Articles were eligible if they described clinical studies of human patients with nontraumatic chronic hand ischemia who underwent sympathectomy, arterial bypass, or venous arterialization. A retrospective review was then completed of all patients treated for chronic hand ischemia by the senior author. Charts were reviewed for operative technique, postoperative course and follow up. Primary outcome measures for both portions of the study included improvement in pain, wound healing, and development of new ulcerations.
Results: Thirty-three studies that met inclusion criteria were identified and systematically reviewed showing that surgical sympathectomy, arterial bypass, and venous arterialization were all effective in treating chronic ischemia of the hand. Bypass and arterialization were both associated with the most consistent improvement in pain (100%; sympathectomy = 89%), whereas arterial bypass had the highest rate of postoperative healing of chronic wounds (93%) (sympathectomy = 74%; arterialization 75%). Sympathectomy was associated with the lowest rate of developing postoperative ulcerations (0%; bypass = 3%; arterialization = 8%).
Chart review identified 16 patients (19 hands, mean follow up = 9.0 months). Eighteen hands had arterial sympathectomies, 6 had ulnar artery bypass with vein graft, and 2 had venous arterialization. Seventeen hands (89.5%) healed their chronic wounds and this was highest in the arterialized hands (100%; arterial bypass = 83.3%; sympathectomy = 88.9%). Fifteen hands (78.9%) had improvement in their pain symptoms (sympathectomy = 83.3%; arterial bypass = 83.3%; arterialization = 50%). Two patients (12.5%) were able to reduce antispasmodic medication after surgery. Zero patients developed new ulcerations postoperatively.
Conclusion: Sympathectomy, arterial bypass, and venous arterialization are efficacious treatments for chronic ischemia of the hand. An algorithmic approach to chronic hand ischemia relies on imaging studies which categorizes patients as having no identifiable vascular lesions, discrete interruptions of patency with reconstitution of flow, or occlusive lesion without reconstructible targets. Based on vascular anatomy and occlusive lesions, appropriate counseling can be given and one of the three surgical techniques can be selected for each patient.
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