Distal Upper Extremity Bypass for Hand Salvage
Julia Kleene, MD1, Robert Shaw1, Jeffrey Hnath, MD2, Benjamin Chang, MD2, R. Clement Darling, III, MD2.
1Albany Medical College, Albany, NY, USA, 2The Vascular Group, Albany, NY, USA.
Objective: Outcomes for tibial and pedal bypasses are fairly standardized, however bypass to their counterparts in the forearm and hand are less common and less well established. The purpose of this study is to evaluate bypasses distal to the brachial artery for limb salvage. Methods:The registry of a single vascular group was queried for bypasses to a target artery distal to the brachial artery. Bypasses for fistula related ischemia were excluded. Indications, demographics, procedural details, and outcomes were tabulated using standard statistics.Results:
From 2007 to 2017, 52 forearm and hand bypasses (30, 57.70% male) were performed for gangrene (19, 36.54%), acute thrombosis (17, 32.96%), ulcer (5, 9.62%) and ischemic pain (5, 9.62%). Comorbidities included, hypertension (41, 75.93%), hyperlipidemia (30, 55.56%), renal insufficiency (30, 55.56%), coronary disease ( 32, 59.26%), tobacco use (24, 44.44%), diabetes (24, 44.44%), thrombophilia (3, 5.56%), history of DVT (3, 5.56%). Inflow was axillary (3, 5.56%), brachial (36, 69.23%), radial (6, 11.54%), ulnar (7, 13.46%). Outflow artery was radial (22, 42.31%), ulnar (13, 25.00%), palmar (13, 25.00%) digital (4, 7.69%). Conduit was excised vein for all cases. Perioperative complication rate was 11.54% overall, wound infection (3, 5.77%), hematoma (1, 1.92%), postop MI (1, 1.92%), immediate occlusion (1, 1.92%). Cumulative patency rate was 90.61% for 18 months. 3 of the 5 late occlusions had risk factors for occlusion; 1 thromboangiitis obliterans, 1 ulcerative colitis, and 1 lung cancer. 1 of the 5 occlusions underwent left arm amputation. 2 patients with patent bypasses underwent amputation, 1 digit amputation and 1 wrist disarticulation.Conclusion:
Upper extremity ischemia symptoms are much less common than in the lower extremity, resulting in a less robust volume of data driven recommendations. This study supports aggressive bypass to forearm and hand arteries, resulting in excellent limb salvage and patency.
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