ICL for the ischemic hand. These are our learning objectives, which are in your app. And this is our faculty, Warren Hammert from Duke, Scott Levin, who won't be here, but he sent his video, John Lee, and Dave Roosh. We'll start off and do a little, just a little bit about the evaluation. This is something that you all know, would sort of just highlight some things. As you know, the hand provides prehensile function, tactile input, and thermal regulation. And within that thermal regulation is the crucial part of what keeps the hand alive and what causes ischemia. And that's only about 10 to 20% of total flow is nutritional. Obviously, this shifts when your hand is warm. It's actually less nutritional, and there's a lot of blood flowing around through those AV shunts. The key to this, and if you think about it, is the temperature. And if you look at it as temperature goes up, at about 30 degrees, blood flow is incredibly good. Okay, that's sort of magic why you feel with the back of your hand, you can tell where it differentiates. At 30 degrees, there's a lot of blood flow. As you drop down, it drops down almost geometrically, and then it levels off. So 30 to 39 degrees, you've got plenty. And when we used to use temperature for replants, we never had a replant die that had a temperature of over 30. Now, of course, in that, you need effective flow. You need a balance between your blood vessels and control mechanisms. And that's what gives you, as you'll see in the talks about vasospastic and vaso-occlusive disease, why you can have adequate flow for perfusion to keep the cells alive, but because it shunts because of abnormal autonomic function, that you get ischemia and ulcers. There's lots of variations. If you look at that classic article by Coleman and Anson, there are over 650 variations. What's the constant is, at the metacarpophalangeal joint level, there are always three common vulvar palmar digital arteries. If you don't see that, it's abnormal. Ischemic pain can be devastating. It can cause gangrene, amputation, but it does depend on the magnitude of the insult and where that occurs. If it occurs before collaterals come off, then you're gonna have more symptoms. And, of course, underlying vasomotor abnormalities can compound what happens. So now, the degree of compromise is important. So if you've got only 20% of flow, but it's all going to the right place, you'll be fine. So we have critical, subcritical, and noncritical. Obviously, critical's easy. If you don't revascularize it, it's dying before your eyes. It's the subcritical and noncritical that are crucial. And these have variable signs and symptoms. As we've talked about, nutritional perfusion is what's crucial for survival. But the quality of that flow is what makes your life happy. It needs to be able to respond to stress. It needs to be, and that's crucial for optimal function. And that gives you good healing and health-related quality of life. And you don't have white fingers like on this. The history and physical, you all know. What happened? Is there a trauma, insult? Is there an underlying disease? And the symptoms of those are vascular insufficiency or nerve irritation. And they're relatively nonspecific, so you have to sort of look at what's going on. Color, temperature is crucial. And we talked about 30 degrees is sort of the point at which there's almost always adequate flow. And if the thermoregulatory allows enough nutritional component, you're good. Allen test is helpful. Pulse is important, and you'd, of course, like to have triphasic pulses that you can look at or listen to with a Doppler. And you want to avoid stenosis and occlusion. Doppler evaluation is helpful, and you can look at flow, and you can look at the quality and where clots are. But what I'd like to emphasize is something that's pretty easy to do is segmental blood pressure. It's a way to differentiate within that subcritical zone what is gonna give you real problems and what isn't. And it's digital blood pressure divided by brachial blood pressure, and it's pretty easy to measure. Just like in the ankle, if it's less than 0.7, you're gonna have symptoms and problems. If it's greater than 0.7, you're gonna do pretty well. If it's less than 0.5, then you've got severe symptoms. But if it's between 0.7 and 0.5, that's what a lot of this talk is about. That's ischemia, but it's relative, and how do you deal with that and make it better? We've talked about the components of flow. There's a way to look at nutritional flow. Here, if you look at the top, it's temperature. If you look at the bottom, it's laser Doppler. And you can actually look at nutritional flow by vital capillaroscopy. And this lets you evaluate exactly nutritional blood flow. But practically, if you look at temperature, Allen test, and digital pressures, you can do pretty much everything that you need to do. This is just sort of some of the icing on the cake. And then, of course, arteriography. And I would always recommend that you consider that. It's helpful, and sometimes you find things that you don't think you'll find, as in this patient who has an occlusion of his radial artery, but he has an aneurysm of his ulnar artery as well. You can do subtraction, and of course, CT angiography is getting better and better. Don't forget the impact of coagulation studies, factor V Leiden, protein SNC, and antithrombin 3. They're important, they cause coagulopathies, and it impacts the results of intervention as well. So hand ischemia, the treatment goal is easy. The trick is when to do what. And what you wanna restore is nutritional perfusion that's pulsatile in response to stress. So, in summary, the history and physical is critical. You can make most of the diagnosis from that. Physical exam is valuable, and there's testing that can be incredibly helpful. Thank you. So our next talk will be, Dave? Get this up. Dave Roosh from Duke is gonna talk about occlusive disease. My charge this morning is to talk about basal occlusive disease and these are the ones that you sort of hate to see. I think this is a great article for you if you're kind of just getting started into this. We wrote this many years ago but it does look at things from a 40,000 foot perspective and kind of helps you to distinguish between basal occlusive disease, basal spastic disease and then those patients that have some combination of both which we used to refer to as having both lice and fleas and so that does exist. For basal occlusive disease the proposed pathophysiology as the slide by Dr. Komen, it indicates that you have some element of trauma, usually repetitive which results in disruption of the internal elastic lamina, allows an aneurysm to form which results in turbulent flow and subsequent thrombosis on the sides of the aneurysm and then distal embolization which is really what the problem is. Patients present with sort of acute pain usually for the ulnar artery it'll be ring and little, you'll see purplish discoloration, index and long and thumb usually will be radial and it's due primarily to the distal embolization from the straight shot from the ulnar artery down to the two hypothenar digits. Basal spastic disease typically is going to present a little bit differently, it'll be more with smaller ulcerations at the very tips of the digits, there'll be penciling of the digits due to chronic insufficiency of the pulp and then burgers you'll see more diffuse involvement with more profound ischemia as you can see in this patient on the right. The physical exam, you really can't ever do more complete physical exam than you will in these patients looking for a brewery or a thrill everywhere from the subclavian down, looking for pulses in all of the major vessels. And then if you don't have one, a handheld Doppler in the clinic is really critical for this. You almost don't need, as Dr. Richard Goldner used to say, you really don't need an ultrasound, a curiogram if you get a handheld ultrasound in the clinic. And then certainly lab studies and checking for cardiac abnormalities as well as any type of coagulopathies on down the pike and then finally as Andy alluded to a digital brachial index is very reassuring to you that you're observing the correct patient. Diagnostically, I start with an arteriogram. I think it should include the subclavian vessels so you're starting down at the femoral artery and you want to make sure that you see all of the subclavian and great vessels. Frequently, you'll see obliteration of the ulnar artery in these and then most importantly as Dr. Komen pointed out to us in a classic article, you'll see a second cutoff out distally at the level of the PIP joints. Occasionally, you will see a patent aneurysm. These will be the ones that your radiologist won't call but what you'll see is that kind of characteristic corkscrew appearance of the aneurysm as there is turbulent flow in that disrupted internal elastic lamina. It'll bulge out on side to side and it'll look like a corkscrew on your arteriogram and that's a patent aneurysm. We looked at arteriography as it relates to patient's symptoms and a variety of other studies found that arteriography really was not a direct correlate to patient's symptoms and function and that scanning laser Doppler really was a much better study for us to use but when you're looking at surgical options, I think an arteriogram is an excellent tool to look at and decide what you're going to do from a preoperative planning perspective. And then DBI obviously is incredibly helpful in terms of deciding whether or not the patient actually requires reconstruction of their vessel. When you look at treatment options, you have everything from observation including vasodilators to thrombolytics and subsequently to surgical options which include resection and ligation versus reconstruction. Thrombolytics are very attractive to us in conjunction with either a catheter or not. I think it's indicated for acute thrombosis or re-thrombosis after a graft and it does give you some time to perform an elective procedure as opposed to one that you're going to be doing in the middle of the night. Some options, streptokinase, urokinase, TPA, they're all have their own problems but you can see here in this acute thrombosis at the top and then after administration of TPA you can see this aneurysm and that allows you then to decide where you're going to plug into and where you're going to take off. Concerns are that there are some problems with these medications from a systemic perspective and there is some question about what becomes acute versus when is it chronic and also are you going to put this patient on long-term anticoagulation which is really kind of what you're obligating the patient to do after performing this. Surgical indications are going to be either resection and ligation versus arterial reconstruction and resection ligation may be indicated in some cases either a poor candidate for a bypass graft or one that has abnormal tone but has DBI greater than 0.7 and that may be to prevent the possibility of further distal embolization which would compromise that distal runoff. When Dr. Komen and our group looked at arterial reconstruction for ischemic hand and wrist, we looked at 23 extremities, each involving occlusive disease at least two levels. I think that's one of the critical things out of this paper was that it was not just down at the wrist. You saw this occlusion at the wrist. That was painfully apparent. Everybody could see that but patients didn't become symptomatic unless they had a distal embolization which usually occurred at the level of the IP joint and that was when they began to have symptoms. And these patients underwent a reconstruction using a branched saphenous vein graft and this is one such case. You can see the branch graft coming out and reconstructing the arch. And one of the things you see in this is sort of the tendency to make your graft a little bit too loose. You can see this would be one that I would probably not accept any longer because the graft is actually put in with a little bit of laxity. You want these put in about 10% of shorter so that there is some natural tendency of the graft to elongate as you put it in. But this is what that would look like as we reconstruct the arch using a branch graft. When we looked at these using the standard tools that Dr. Komen alluded to, we found that their hand symptom function scores improved, their hand function scores improved, pain improved. Oddly enough, and this is sort of consistent with our literature, is that the cold sensitivity for these patients, despite having a patent graft, the cold sensitivity persisted in these patients for at least two years. So I usually am quick to tell the patients that cold sensitivity is not going to go away entirely despite everything else. The technique is to prep the contralateral ankle for the potential for a vein graft. Extensile approach, we usually do a sympathectomy of the contralateral radial artery as well and then release Guion's canal and carpal canal in order to avoid having to come back for anything in the future. Some tricks, I think I learned from Dr. Komen that a nice trick is to do the distal side first. You can do the, if you do the distal side first back wall, that's the easiest way to get to the back wall on the distal side. So start there and then flip the graft back down and that'll let you do the front side of your graft and you can start that there. As a case example, a 55-year-old smoker, no other medical issues, acute painful ulcerations and bluish discolorations with the arteriogram demonstrating multilevel cutoffs. You want to go proximally and figure out where you're gonna find normal vessel. Andy took a page from the vascular surgeons at the Mayo Clinic who look for a patent side branch proximally and that's gonna indicate that you have normal vessel proximally and that's a good place for you to start and then a branch vein distally going into the long ring and superficial arch as you can see here. And then that's what that would, that's what that typically looks like with a 12 centimeter vein graft and a symptectomy of the radial artery with a resolution of the symptoms at three months and no further discoloration or ulceration. Radial artery also gets vaso-occlusive disease. This is frequently misdiagnosed as carpal tunnel due to the involvement of the thumb and index occurs under the first compartment so it's a little bit more difficult to appreciate. And oddly enough, this is one that you see frequently with vasospastic disease as well. So that combination of lice and fleas exists with the radial artery in conjunction with scleroderma. Extends into the princeps and radialis indices and again, this is a critical one to do the distal side first. So this is a radial artery involvement with ischemia of the entire hand and you come down, find your patent side branch, approximately it's underneath the first dorsal compartment. You're gonna go out distally and go into the radialis indices and princeps pollicis with your branch vein graft. And when we looked at these patients at 22 months, we had excellent patency rates for the radial arteries and one thrombosis at five years. So very, very easily reconstructed. I think anymore, when we start talking about doing these operations, the biggest thing we're discussing is our graft choice. We are finding there are saphenous vein grafts that we relied upon for so many years are starting to fail at about 11 to 14 years and this is one such patient who had an aneurysm that I resected and grafted and at 12 years, he represented with a thrombosis which extended more approximately, involved more digits and he was managed with heparin and chronic anticoagulation. Oddly enough, we were able to salvage the majority of his hand after six months of anticoagulation but I think that at this day and age, dealing with a younger patient with a hypothenar hammer, we had one such individual, I think with a hockey player, a young adult hockey player and we chose a arterial donor for the vein graft. So that's probably where we are now with these excellent operation, excellent patency rates and a high degree of satisfaction. So in conclusion, hypothenar hammer is a common cause of ulnar-sided digital ischemia. Reconstruction provides, I think, a very reliable reversal of ischemic symptoms with the exception of cold intolerance which does persist. Graft failure is starting to become a problem. After you do something for long enough, you start to realize what the touch points are and graft failure seems to be one of them. So I think we need to continue to look for a easy, reliable donor vessel that doesn't involve going up into the temporal region or even back into the shoulder. So with that, I'll conclude and thank you for your attention. Thank you. Good morning, I feel humbled to be part of this panel of world expert, as a non-expert. So I'm gonna talk about iatrogenic cannulation and vasoactive drug-induced events. I have nothing to disclose. You all know radio artery now is the choice for cardio cath because compared to intrafemoral access, radio access is safer and easier. And complications in general is very low because it's lower than femoral access. But we still see those patients, they'll call you for the complications. But luckily, most of the complications can be treated without surgery. But if a patient show up in your office with a hand ischemia because aneurysm or AV fistula or occlusion, they need a surgical intervention sometimes. So oftentimes being called, patient has bleeding problems, hematoma after cardio cath. So those patients can be treated with compression, hold off anticoagulation. Arterial perforation, also same thing. You can, compression can stop the bleeding most of the time. The most common complication after radio artery access actually is occlusion. So a study looking at those patients critically, as high as 10% of patients will have radio artery occlusion. So the consequence is a loss on the donor arteries for bypass, but majority of patients are doing fine hand-wise. So a small percentage will have ischemia. And AVF is rare. Some case report, treatment is quite straightforward. You need to tie off AV fistula. And pseudaneurysm is, incidence is very low, five out of 100,000 cases. But think about how many cardio cath being done nationally every day. So you'll see those patients sometimes. We know aneurysm is dilation of the whole vessel. Pseudaneurysm at least has one layer of vessel wall is compromised, cause of bleeding, and starting collecting of blood or clot. And those patient come to see us with a mess. Could it be painful, sometimes bleeding. Some may have renalts because of either spasm or finger ulcers because microembolism, distally. That's a typical healthy flow, biophysical flow. And this, as Dr. Roush mentioned, it's a patent aneurysm, the turbulent flow. Colorates with angiogram very well, you can see. Ultrasound is very helpful. You can see the leak from the vessel wall into the aneurysm here. And color Doppler showing called yin-yang flow patent because we know the Doppler put on the vessel, you have flow either toward the probe or away from probe. But it was turbulent flow, you still have both flows. Part of the flow goes toward the probe, part of flow moves away from the probe from this yin-yang flow patent. So this one of our patients, she had a cardio cath, sees small mess over the anterior side with pain and hand swelling that you can show, see the leak from the radial artery into the pseudoaneurysm with the yin-yang flow. Treatment, as I mentioned, Dr. Coleman and Dr. Roush mentioned, it depends on the collateral circulation. So excise the aneurysm. If we can repair primary, repair primary. If we have to do more than repair, it depends on collateral circulation. Either ligate tight the vessel if collateral circulation is adequate. If it's inadequate, we have to do graft or venous patch to patch the area of defect. Talking about iatrogenic cannulation. So iatrogenic cannulation happens, one study is showing one out of 3,400 to 56,000 cases. So that's a big number. You see how many anesthesia being done in the OR. Most common iatrogenic injection is due to abnormal anatomy. Radial artery can be superficial. So superficial radial artery cross the first dorsal compartment, the snuff box area, superficially, being mistakenly as a vein can cause a problem. And there's increased incidence of injection into the artery by the drug abusers. So we all know that, we all deal with those patients. So globally, there are 16 million IV drug abusers. In the US alone, more than three million. So we have more than 1% of the drug abusers. And the federal government budget for drug control is $35 billion. So a lot of money, a lot of patients you're gonna see in your institution. So it happened, medically, iatrogenic injection, most common is antibodies, antibiotics. Antibiotics or barbiturates. Most of the time, they're diluted. They typically were fine with flush with IV. But for drug abusers, can be anything. Can be crushed tablets, powders. So can cause acute ischemia, pain, infection. And there's high percentage of patient end with limb amputation. So what's the pathophysiology? Those compounds can directly damage the endothelial layers, cause thrombosis. And also can induce vasospasm when the tablets can form, crystal can form embolism, can clot the distal vessels. So now you have clotting from distal vessels, thrombosis because endothelial cell damage, endothelial spasm all contribute to the ischemia. Plus, locally has cytotoxicity, lipid solubility and a high osmolarity cause soft tissue damage. So those are typical patients. You can see the unmodeled skin color and ischemia. So you're looking at natural history. Patients starting feeling pain, numbness. Then skin color changes. Swelling eventually cause the gangrene or amputation. So time is critical. If what happens in the hospital are genetic injuries, don't take the catheter out, leave it in. Starting IV infusion, get angiogram, confirms diagnosis. If patient condition allowed, start anticoagulation. For drug abusers, you try to quickly get a baseline angiogram to access to evaluate the extensiveness of vascular pathology. So this recommendation, number one, to control pain with blocks, pain medicine. Number two is prevent vasospasm. Starting calcium channel blockers, alloprost can, started showing alloprost can help to dilate the vessels. And restructure flow by angiogram, confirm the embolism, starting fumblytic therapy for a patient shows up early. And then you treat the other complications later. The other thing is antibiotics. So starting antimicrobial therapy early. They're looking at the catheter-directed fumbolysis. So get angiogram in early patients, they show up early, less extensive fumbosis, so the arteries. Starting the angiogram, starting lysis, then repeat angiogram the second day, and same time starting antibiotics. So those patients can help them to save the limbs. But luckily, most injection drug abusers, they choose the arm vessels instead of forearm vessels. They'll go to vascular service instead of us. If someone comes to the hospital late, they have extensive fumbosis, the arterial lysis is not gonna work, so need to open a thrombectomy. So the patient, she's a 30-year-old drug abuser, you can see extensive fumbosis of the brachial artery, so needed open thrombectomy. The worst scenario is someone coming with pus, blood, and soft tissue mass, post-op mass. So those are infected pseudaneurysm, has high rate of amputation. There's no standard protocol how to manage those, but common wisdom is you have to tie the vessel, do extensive debris mount, and see if a limb survives, then do reconstruction. Don't do the non-selective revascularization because complications are high. The example patient, drug abuser, multiple broken needles in the arm, pseudaneurysm, he is after vengraft, a flap, returned with draining pus and a ruptured aneurysm, and it was amputation. So look at his outcomes. This is a Finland study. They have 24 patients, all young, we know that. Most common is benzodiazepine and buprenorphine injection. So one third of patient ended with amputation. Recommendations, early angiogram, early antibiotics, anticoagulation, aeroprost infusion, which was a vasodilator, and also do ubriculopraxis block to dilate the vessel and control pain can help to save some of the limbs. So time is critical. Systemic review showing if a patient being treated within 14 hours, amputation rate is 4%. If after more than 14 hours, amputation is 46%. So there's more than 11 times increase of amputation. Treated them early. Quick mention about epinephrine injection. We know epipen being widely used, and it happens sometimes by accidentally deploiting the fingers. Also, people use a local block. Multiple studies showing epinephrine injection to the finger is safe, although we try to avoid it. Ischemia is rare, most of the time self-resolving. Some case reports of fingertip necrosis. Most of the time, just watch them. You may try to use warm water or topical nitroglycerin. If a severe case, you don't feel comfortable, may try to local injection with 1.5 milligram of fentolamine, which is alpha-adrenergic receptor antagonist, mixed with 1 cc or 2% of lidocaine. And most of the time, you can reverse ischemia. In summary, so iatrogenic arterial cannulation, or unintentional arterial drug injections are rare. Most of the time, can be treated safely with non-surgically. But if a patient showing up with ischemia, we need to do vascular reconstruction for pseudoaneurysm or occlusion or AVF. And there's increase of IV drug abusers, they stick a needle into the artery by accident or by intention. And those patients has a high rate of amputation. So you should treat them early. It's time is very critical. Thank you for your attention. Thank you. Our next speaker is gonna be Warren Hammer from Duke. While he's coming, let's see if I can get this open. My worst cannulation injury was I had a vein graft for the radial artery up on the wrist. It was pulsating, went down into the snuff box, and the anesthesiologist thought that would be a real easy vein to cannulate. She lost her thumb. Let's see. No. Yeah, we just hit close. Yeah, I finally figured this out. Well, good morning. Thank you for coming out early. This is always a hard time after everybody's been out Friday night and had a nice time in a nice city, hopefully. So my charge is to talk about diagnosis and management of penetrating arterial injuries and when arterial reconstruction is important or crucial. I have no disclosures related to what I'm gonna talk about here. The first thing I'd say, if you wanna know the answer to this, just look at Dr. Komen's article from last year in the Journal of Injury because he talked about management of upper extremity arterial penetrating vascular trauma. I'd point out throughout his career, he's got 1,500 revascularizations and replantations, so quite a remarkable number and certainly well more than I have, so he's much more of an expert than me, but I'm gonna try to give you thoughts on how to approach this problem. I'd say sometimes it's obvious. Dysvascular hand with no distal or palpable or doppler repulses, this obviously needs to be reconstruction, but they're not always like this and so making a decision can be more challenging at times. When you think about combined injuries to the forearm where you've got lacerations, maybe the radial and ulnar artery are both cut and there's warm fingers, well perfused, you need to fix those. How do you decide? Penetrating injuries exploration can often be beneficial just because you need to remove the foreign bodies, but what needs to be reconstructed and when is it important to repair one artery if there's one that's patent? Distal injuries may not cause ischemia, but they can cause other problems and so these are another examples of things that you need to think about how do you address. So the considerations for this are which vessel or vessels are injured, the location and mechanism of the injury, is it something that was crushed and ripped apart or is it a sharp laceration? Underlying skeletal trauma has a role in this. The ischemic time, the pre-injury comorbidities and overall health of someone that's got severe COPD is different than the otherwise healthy person and then there's more of a civilian type of an injury, is it a stab wound or is it a ballistic or a war type of injury because those all come into play when you're trying to figure out how to manage this. I'd say that the outcomes are probably affected more by the other injuries than the vascular injuries. The skeletal injuries, the nerve injuries, compartment syndromes, infection from necrotic muscle that's been debrided a few times, all of those are gonna affect the patient's outcome more than the vascular repair typically, the decision for that. Also when you think about pediatric patients, they're different than adults. They tend to have penetrating trauma more than blunt trauma. Upper extremity is more commonly affected in kids, males more than females, but amputations are much less common in kids fortunately. There's also things that come into play with kids that are not with adults. So you have to think about the osseous development. How is this ischemia or chronic ischemia gonna affect the bone development, bone growth? Basal spasm is more common in kids. They tend to have more vascular reactivity. Think about the growth that needs to occur. So in a child, they need to have that vessel grow with the rest of the limb. Is that going to be an issue? And then overall, because they're smaller, they have a lower circulated blood volume. So if they've lost a lot of blood, the overall physiologic effects of their blood loss may come into play more so than with an adult. So when you think about arterial injuries, I break these down into kind of two categories, the critical injuries and the non-critical injuries. And so for a critical injury, it's where there's really something that's not gonna survive without repair. So it will result in cell death, necrosis, and subsequent amputation. And then the non-critical injuries are where there's collateral vessels that may still provide some distal flow. And in this situation, we know that the resting arterial pressures are lower than the contralateral side. Exercise tolerance may be decreased. So if you have one vessel to the hand as opposed to two, you may have some difficulties with muscle mass. You may have more cold sensitivity. So what's the role for fixing non-critical arterial injuries? And then the next thing to think about is what is the anatomy like and how do we make this decision? If you look at the superficial palmar arch, this tends to be continuous about 80% of the time. So four out of five times, everything's gonna be provided by just the superficial arch itself. The deep palmar arch, almost 97% of the times, this is gonna be complete and you'll be able to perfuse the entire hand off of either one of those vessels by themselves. But there are variations in vascular anatomy that you have to think about. So an example of a couple different variations here in the brachial artery and the anterior interosseous or an interosseous artery that's persistent. And this may explain why sometimes when you have a laceration, you say the radial artery, the ulnar artery's cut, the hand is still perfused because there's a persistent interosseous artery, median artery, or something else. If you look at the variations, about 50% of the time, there's some sort of persistent or persisting median artery. There's different descriptions of this. You can have a high takeoff of the radial artery from the brachial artery rather than below the antecubital fossa. And then other variations, an accessory brachial artery where there's actually two arterioles support to the hand. And then superficial ulnar artery in the distal forearm and the radial artery. So what you go through with this process. The first and I think the most important process in dealing with these injuries is the debridement itself. If there's been prolonged ischemia, you wanna think about shunting initially. And then stabilize the skeleton, perform fasciotomies as needed, and then allow the patient to bleed to clear the metabolic waste. You wanna get everything out of the system that you can. And then your vascular and other repairs, wound closure. But when injuries like this, you wanna really think about a second look at 48 to 72 hours. Because if you get infection around your vascular repair, your vascular graft, that can lead you to failure and amputation. So when you're thinking about doing the vascular repair, this is some descriptions from Andy's article, but very good to help think about the mismatch of the size. So if you need to do a graft, ways to make your vein or your arterial graft match your native vessel. You can make that slightly larger by angulating it. You can narrow one by making a longitudinal incision and closing that. I'm always hesitant to make a vessel smaller. I like to make one vessel bigger if I can, rather than making one vessel smaller. I've never done this picture that's depicted on the right. I've seen it in diagrams, but interception where you bring the proximal end into the distal end and allow flow. Patency rates are better for critical injuries than non-critical injuries. We know some of our data with chronic ischemia, such as ulnar artery reconstruction for hypothenohammer syndrome. If there's a patent hand, the long-term patency is less likely to be maintained. So with single vessel forms, generally 50 to 93%. If it's the radial or ulnar artery, then about 80 to 90%. Postoperatively, you wanna avoid vasoconstrictors, keep the limb warm. I think aspirin's been helpful. The other anticoagulation medicines really have not been proven to be beneficial. There's a lot of kind of voodoo and hocus pocus, and I always use this. I use heparin, I use dextran. There's not really any science to suggest that those increase the long-term patency rate other than aspirin. So how are we gonna assess or predict these based on the injury? I think for this, the mangled extremity severity score and the injury severity score are helpful in children and adults, and it does correlate with outcome, but it doesn't predict complications, how they're gonna do long-term or amputations. So in summary, I think acute vascular repairs are indicated for anatomic reasons. If there's an injury proximally, such as the subclavian or axillary artery, an injury to the brachial artery, injury to both of the arteries in the forearm, segmental arterial lesions where you have two or three, those are gonna be probably better treated with an arterial graft or a venous graft to reconstruct that, and if they have preexisting occlusive disease in one or both vessels. If there's decreased capillary refill or if it's greater than six seconds based on an Allen test, that's a time you'd wanna consider reconstruction. If it's a pale but pulseless extremity, obviously you want to do that even if the vessels seem to be intact because there's a thrombus that maybe need to be excised, as Dr. Lee showed us, and if there's poor backflow, then you know that there's probably not as ideal patency as you'd like, and that's another time that I'd think about reconstructing it. Thank you. Scott Levin couldn't be here, or we could do some questions now. What would you all like to do? Video, all right. Scott apologizes. He was here, but he had to leave. I booked him for a 23-hour observation and put him on 800 of heparin overnight, discharged him on Plavix. I'd like to talk to you about critical vaso-occlusive and occlusive disease when peri-arterial sympathectomy is not enough. These are my disclosures that are not pertinent to this talk. The following subset of patients will present to you with ischemic pain in the upper extremity. They include patients with lupus, Raynaud's disease, peripheral vascular disease and arteriosclerosis. Patients with renal insufficiency that are on dialysis and have calcification of their vascular tree. Referring physicians to your practice will include fellow hand surgeons that are not comfortable with treating peripheral vascular disease or the microsurgical techniques that I'll share with you, vascular surgeons who may be uncomfortable treating patients in the forearm other than AV fistulas and do not have interest in or understanding of how to treat peripheral vascular disease in the hand or digits. Rheumatologists who are managing patients with mixed connective tissue diseases that have medically maximized their patients and yet patients still have symptoms. The nephrologist obviously caring for patients with renal failure and calcification of their end arteries, endocrinologists managing the diabetic that has compromised nutrient flow or ischemic changes, and hematologists who treat a variety of blood disgraces that may predispose a patient to a hypercoagulable state that results in vascular occlusion on the arterial or venous side that requires intervention. It's all about improving inflow, and this can be done by working with our vascular interventional radiologists. Their techniques have come a long way in the last many years. You alone interpreting clinical evaluation of the patient, a Doppler exam in the clinic, the MRA or imaging of the vascular tree, pointing out, say, an ulnar artery occlusion or digital ischemia that you think you can bypass. A combination of working either with vascular radiology or our vascular surgeons where they might perform proximal bypass in the carotid axillary or brachial artery, and then you complete the inflow anastomosis distally using microsurgical techniques. The interventional radiologists have made great advances in their abilities to do angioplasty with minimally invasive techniques, place stents that are often reserved for patients who have brachial artery or vein occlusion. They can do a variety of thrombolysis procedures, for example, on the venous side of instep veins as well as arteries, and of course, minimally invasive atherorectomy or endarterectomy using catheter-directed ablation of vascular atherosclerotic lesion. This patient had hand pain following creation of an AV fistula. Our vascular surgery colleagues took the fistula down and then referred the patient to me, and I subsequently did an arteriogram on the patient and then engaged my vascular interventional colleagues. Radial and ulnar artery occlusions, as you see here, radial artery was crossed with a microwire and then a support catheter, and here's the radial artery with a 2.5 millimeter balloon being angioplasty, the ulnar artery, same balloon size, and look at the inflow to the hand now after radial and ulnar artery angioplasty, not only proximal flow has been restored and collateralization, but great flow to the patient. Here's a patient with a brachial cutaneous fistula that had a steel syndrome, ischemic hand pain, concerned about ongoing ischemic changes. Clearly, this patient is going to need an amputation revision, but you should be thinking more in the lines of what is the inflow I have to get a safe level amputation where we don't perform an amputation, have inadequate inflow, continued necrosis, and need for more and more proximal amputation levels. You do this working with our, again, vascular interventionalists. You can see the stenosis in the radial and ulnar arteries, and the ulnar arteries occluded here, very ratty looking vessels. Here's the distal radial being opened, the radial artery angioplasty, this time with a three millimeter catheter, post-angioplasty, ulnar artery now opened up with a two millimeter catheter to include with inflow, and here's the completion arteriogram on the table. This patient may or may not also benefit from a sympathectomy at some point, but sympathectomy alone clearly would not have opened up these vessels, and ultimately this patient went on to go as a successful PIP joint level filet flap and amputation, preserving as much as it can. We've reviewed our interventional radiology results in the forearm with publication in the Journal of Endovascular Therapy, 89% technical success in 30 patients, 38 arteries, and the median primary patency, 281 days. These techniques are not perfect, but they can buy time, they can increase collateralization, and you may be wondering, what do I do with the other 11%, and that's when we'll discuss arterialization of the venous system, where our interventional radiologists cannot augment forward flow, and then it's back to you, and you have to come up with a solution to avoid hand or digit. But often we work with our vascular surgeons. This is a patient that had intractable forearm and hand pain, several occlusions of the axillary and brachial artery, attempted stenting didn't work, so the vascular surgeons and I teamed up. This is a carotid to palmar arch bypass, and you can see the long saphenous vein. One of the things technically that's important, and we learned this from coronary bypass, is to mark the vein graft, particularly long vein grafts, with a skin marker, so we maintain orientation. You open the graft, make sure there are no leaks, and then the tunnel, as you see here, from carotid through the neck, through the upper arm, antecubital fossa with the tunneler, down to the arch, and this patient continued to do well for a fairly long period of time, obliterating the symptom. Here's an alternative to using vein grafting, and thoracodorsal artery has been described as a very good graft to use, not only based on caliber, but replacing like with like. Professional hockey player who developed an aneurysm of the ulnar artery. You can see us opening the aneurysm. Here is the approach, as you can see, the aneurysm is resected. We want to get back to normal, healthy lumen, which is critical, and you can see on the left side the clitor clamps. This is the target, approximately is the origin. We do what we call an extra-anatomic, or along the hypothenar border of the hand to avoid further impaction or recreation of the aneurysm, even in the thoracodorsal artery that we harvest. A year and a half later, good function, went back to playing professional hockey. Hearing is believing, and that's the result at one and a half years. We can also bypass the digit. This is a patient that presented with exquisite pain, intractable ischemia, calcium channels, blockers didn't work, the mixed connective tissue disease workup was next, and here is the arteriogram showing almost complete obliteration of circulation to the index finger. We used venous interposition grafting, and certainly before proceeding with the amputation, we opened the digit, we found not only the radial artery, but the ulnar artery occluded, but had a soft spot approximately, and distally at the level of the DIP, we're able to find a target. You could consider the close-up view of the digital, and here is the graft in place. It took a little longer than we usually do, and the patient ultimately, and here is one and a half years post-op with no further ischemic changes, and that's bypassing and reconstructing the pulp. Finally, arterialization of the venous system is something you should consider when you don't have distal targets. This is a patient with chronic renal failure and bilateral below-knee amputations from peripheral vascular disease. The left hand became ischemic, you can see the index, and we did a long ulnar artery to palmar arch bypass, ultimately a digital amputation that healed of the index finger because of distal osteomyelitis. Ultimately, as you can see here, there was a healing, took several months, but good capital. Then the patient presented with the same situation on the right side, you see the ischemia and lack of flow, and there was no distal target, no ability to angioplasty, stent, or bypass, and these are the cases where you consider, again, similarly to what we did on arterialization of the venous system. Here's the right side, and ultimately the patient, we did a completion amputation about two months ago, she is in the clinic, both hands preserved, and you see the venous actasia of the AV fistula that we created to provide nutrient and forward flow. So this hand was arterialized, how long ago, Sharon? Last year, in July. No ulcers, hands nice and pink, you heard the signals here, so this has done very well. And then we just arterialized, you can see here, this form, long bypass, and we came off with a bacillic vein, little fingertip that had some pulp necrosis, so we're managing this with just a distal amputation rather than a more proximal one. Here are her signals, arterialized the venous system, you can see a fair amount of dilation, but the best news is that we have a signal here, that's her ulnar digital artery here helping heal this amputation, so you can see the refill, and the fingers are nice and pink, and she's tolerating this fight very well. So she had no distal targets, this was the objective, to arterialize her venous system, and the hand's nice and warm, and certainly an improvement on her preoperative state. And finally, a day without the microscope is a day without sunshine, I hope when periarterial sympathectomy is not enough, you consider bypass, working with your vascular interventionalist, working with your vascular surgeons, it's all about flow. Thank you very much. I'll relay your applause to him, thank you. Any questions, comments? We have a few minutes, two minutes, yes. I think that's a solid question for me. Yes, we see, we just had a patient similar situation. Obviously, we don't want to kill the patient, right? So, you'd rather kill the fingers than kill the patient. Well, patient has, in critical condition, had a cardiac cath and had hand ischemia because of occlusion. So, those patients were typically treated medically instead of surgically. If patient's stable, obviously, you want to revascularize it. But if the medical condition doesn't allow us to do any surgical vascular reconstruction, we just leave them alone, treat it with pain. There's a lot of interesting stuff about growth in kids, and if you go back and look, if you want the references, it's in that injury. Frank Bassett, years ago, looked at the lower extremity, and in little kids, if you ligated the arteries, the arms were smaller. They're older, if they survive, they aren't smaller, but there probably is some fatigue, so Goldner used to talk about that, but I could never find the exact references. It was really Bassett's work, which Goldner reported serious when they did catheterizations with the brachial artery in babies, and they would ligate them, and he said that the arms were smaller, so I think if you do near newborns, they're smaller, but if they're much older, the arms, the length's pretty good, the muscles are a little bit smaller, and we know they have to fatigue a little bit, so I don't know if that answers your question or not. It should, it should, and you can do that if the vessel is patent. We have done that a couple of times, after brachial artery injuries with supracondylars, where they had symptoms, did one a couple of years later, and it changed things, but it's hard to get, there's no good data on that, but I think it actually, it has to happen. I don't have any experience with late reconstruction for those, you know, I always take care of kids as well as adults, but I think once they get through the acute injury process, I haven't seen anybody that I've actually had to look at or even think about that, that's a good question, and I think it's going to come down to judgment, because as Andy said, there's not any evidence to really guide us with this. I think you use fatigability, and that they have a digital brachial index that is, you know, less than .7 as your markers, and then you revascularize them, they ought to do better. When we did computerized testing on these patients, these are adults mostly, we found that if they weren't reconstructed, that they actually did fatigue more quickly. It's hard to test in static testing, their grips weren't much different, their pinch wasn't different, but when you stress them, and you looked at it with computerized, they would, as you would expect. If they don't have enough ability to respond to stress, they fatigue, and the kids have to do that. They develop collaterals, so then it depends on the quality of the collaterals, but you don't want to rely on all that stuff around the elbow, because they can damage it later. I think my thought is the traditional angiogram is still the gold standard and much better for the distal circulation the MRAs are good like for a aneurysm of the ulnar artery even in the palm But when you get distal and you're trying to see what the digital vessels are like I've been underwhelmed with both MRAs and CTAs I just don't think that the at least the places that I've worked have the details whether it's machine whether it's Positioning or what to get what you need to try to make a decision. Can I bypass this or not? I think Even our tear grams have their limitations. So I like MRAs for Discrete masses that you're trying to decide the extent of the mass and whether or not it's truly vascular or is it you know a Vessel that's tented right over the mass but I think Being able to watch the dynamic flow and see exactly how the flow is is getting into the digits is is Priceless. So I prefer to get an angiogram. I agree with you It's a lot more challenging Interventional radiologists are less likely to do it at Duke than they used to be and now we have to actually send them to the cardiac lab So the cardiac cath people actually are the ones doing it It's very CT angiography the vascular surgeons like that better for the brachial and axillary but distal It's it's still we actually it's in ours and use the cardiologist. We use the vascular Surgeons do our arteriograms now Yeah, and it's they're much You know It's much easier to work with them and and it's much quicker and they actually understand the pathophysiology of what we're dealing with If you use MR angiograms or CT's or even regular angiograms It's really important to correlate that with your physical exam your Allen test and to Doppler it because if they have vasospasm Sometimes look like they have no Vessels that you can hook up but we listen or you go and explore them and you see that it's just fine One thing it showed about cannulating Learned this the hard way. So hopefully you won't if you actually put a catheter across an occluded vessel Don't operate on it right away. If you need to operate wait five days because that catheter will destroy The intimate usually doesn't hurt the internal elastic lamina, and you'll keep getting clots So it takes three to five days to restore the intima So if you can put it off put it off It's helping one of our Plastic surgeons we were doing the case and we kept doing the ulnar artery and it would call it off Proximal to where the damage was we finally realized it was from the catheter, but we had to go back an extra Eight ten centimeters to where we could get good vessel and it stopped clotting Any other any other questions comments One other point about the a grams Frequently when we do sympathectomies for scleroderma It will appear that there's a very kind of atrophic radial artery going around the snuffbox on your arteriogram and when you get in there, there really just doesn't seem to be any flow at all and What little flow that you do have there can be substantially improved by a vein graft and we found that in the original series of That Andy and I looked up Ten plus years ago and we we relooked at that again Recently and found that that was the case. So have a have a low threshold for for grafting your your radial artery on your sympathectomies you can generally get a lot better flow than what you had in your preoperative state regardless of what your arteriogram shows Eight grafts increased total flow Sympathectomy increases nutritional perfusion So it becomes your collaterals, but if you to increase total flow you need a patent graft So I have a good collaterals, you know about the MRA and a CTA Do you in your institution when you get a MRA? Do they do reconstruction 3d reconstruction or just yeah, some of those 3d reconstructions are they showed beautiful? angiograms a Lot of times CTAs without reconstruction just looking for the dot. It's very very difficult to interpret. So I have good software do 3d Reconstruction I use a lateral femoral circumflex artery. I'm not doing this in kids very often, but I think the advantage of that is it's a really good size match. It's a place that orthopedic surgeons are generally more comfortable operating than in the axilla. And you can find branching patterns. So for example, ulnar artery, rather than doing end-to-side anastomosis into the distal vessels, I can usually find two or three branches and do end-to-end anastomosis. So I think the lateral femoral circumflex works really well. I like the inferior epigastric. You don't have to flip them up, turn them over. We were worried that it might actually interfere in women if they had to have breast reconstructions. But if you actually just take it from distal, they can still flip it up if they need to do that. Well, thank you all. Have a wonderful rest of the meeting, and safe travels home.

hand ischemia

arterial occlusion

diagnosis

management

vascular interventional radiology

vascular surgery

angioplasty

bypass grafts

blood flow restoration

treatment options