Outcomes of upper extremity interventions for chronic critical ischemia.

Autor:	Cheun TJ; Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex., Jayakumar L; Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex., Sheehan MK; Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex., Sideman MJ; Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex., Pounds LL; Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex., Davies MG; Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex. Electronic address: daviesm@uthscsa.edu.
Jazyk:	angličtina
Zdroj:	Journal of vascular surgery [J Vasc Surg] 2019 Jan; Vol. 69 (1), pp. 120-128.e2. Date of Electronic Publication: 2018 Jul 29.
DOI:	10.1016/j.jvs.2018.04.056
Abstrakt:	Background: Critical hand ischemia owing to below-the-elbow atherosclerotic occlusive disease is relatively uncommon. The aim of this study was to examine the outcomes in patients presenting with critical ischemia owing to below-the-elbow arterial atherosclerotic disease who underwent nonoperative and operative management. Methods: A database of patients undergoing operative and nonoperative management for symptomatic below-the-elbow atherosclerotic disease between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (tissue loss and rest pain) were identified. Three management groups were identified: no revascularization (None), endovascular revascularization (Endo), and open revascularization by bypass (Bypass). Patients with acute embolism, active vasculitis, end-stage renal disease, ipsilateral dialysis access complications of steal, and ipsilateral trauma were excluded. Results: One hundred eight patients (56% male; average age, 59 years) presented with symptomatic below-the-elbow disease: 93% presented with digital ulceration and the remainder with rest pain. Eighty-one percent had diabetes and 41% had chronic renal insufficiency (not on dialysis). All underwent catheter-based angiography. Fifty-three patients (49%) had no intervention and subsequently were committed to wound care; 26 of these required no further intervention, 10 had an interval palmar sympathectomy, and 17 underwent either a phalanx or digital amputation. Thirty-four patients (31%) underwent an endovascular intervention with a median of 1.5 vessels (ulnar, radial, or interosseous arteries) intervened on. Technical success was achieved in 29 patients (85%). Of the five technical failures, two went on to bypass, one had a focal endarterectomy and patch angioplasty, and one was treated conservatively. Ten patients in the Endo group required either a phalanx or digital amputation. Twenty-one patients (19%) underwent a saphenous vein bypass (reversed or nonreserved) to the radial in 12 and the ulnar in 11 limbs. In follow-up, 11 patients underwent open or endovascular intervention to maintain patency of the bypass. There were nine phalanx or digital amputations in the Bypass group. No below-the-elbow or above-the-elbow amputations were performed within 30 days. The wound healing rate without amputation was 78% (85 of 108). The predictors of wound healing were technical success of the revascularization, intact palmar arch and presence of digital run-off. The presence of an incomplete arch and poor digital run-off were associated with a phalanx or digital amputation. Conclusions: Upper extremity interventions for critical ischemia are associated with a high rate of success. Major amputations are rare and the many can be treated nonoperatively. In appropriately selected patients, both endovascular and open interventions have a high rate of success. (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
Databáze:	MEDLINE
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