Bypass Surgery for the Treatment of Upper Limb Chronic Ischaemia

Article Outline

• Abstract
• 1. Introduction
• 2. Methods
• 3. Results
• 4. Discussion
• 5. Conclusions
• 6. Conflict of Interest
• References
• Copyright

Abstract 

Objectives

This study aims to evaluate the results and complications of surgical arterial revascularisation of the upper limb for treatment of chronic ischaemia using infrabrachial bypass. Results of limb salvage and follow-up with graft patency are analysed.

Design

This study is a retrospective analysis of 23 patients affected by chronic upper limb ischaemia and treated by surgical bypass.

Materials and methods

We retrospectively analysed 23 patients with upper limb ischaemia treated between January 1998 and January 2008, by means of bypass graft revascularisation. After surgical revascularisation, eight patients (35%) with digital gangrene underwent minor amputations during the same surgical session, or within the following few days. Postoperatively, patients were followed up at regular intervals of 1, 3 and 6months, and every 6months thereafter, both clinically and with a duplex ultrasound scan.

Results

The mean 34months’ follow-up was 96% complete. Life table analysis revealed a primary patency of 82.6% and secondary patency of 91.3%. Limb salvage was 100%.

During the follow-up period, four patients sustained graft occlusion and, of these, two underwent re-do revascularisation with success.

Conclusions

We believe upper limb bypass surgery represents a valid treatment in this clinical setting, both for limb salvage and for relief of symptoms.

Keywords: Vein graft, Stenosis, Surveillance, Hand, Ischaemia

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1. Introduction 

Arterial reconstruction for the treatment of chronic upper limb ischaemia is infrequently performed in a vascular surgical practice. Upper limb ischaemia requiring surgical intervention accounts for 4% of all vascular surgical procedures.¹, ²

In the upper limb, it is more common to have emboli, trauma or thromboangiitis obliterans than to have chronic occlusive disease.³ The increased survival of patients with chronic renal failure has led to a considerable increase in cases of upper limb critical ischaemia for which medical therapy and/or endovascular treatment have their limits and open surgery proves to be decisive.⁴ In the literature, results of bypass in the upper limb are quite satisfying, with a reported patency rate of 60–90% at 2–years.⁵, ⁶ We report our experience with arterial revascularisation of the upper limb for treatment of chronic ischaemia using infrabrachial bypass. Results of limb salvage and follow-up evaluation of graft patency are analysed.

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2. Methods 

Data that were prospectively entered into the registry of our vascular unit were analysed. We retrospectively analysed 23 patients with upper limb ischaemia treated between 1998 and 2008 by means of bypass graft revascularisation.

Patients treated by thrombo-embolectomy, patch angioplasty and direct suture for acute trauma were excluded. Indications for bypass grafts included: exercise intolerance, rest pain and tissue loss. All patients underwent preoperative evaluation with duplex ultrasound mapping to locate inflow and outflow sites for arterial revascularisation and to locate a suitable venous conduit (saphenous and arm veins).

Patients found to have arterial calcification preventing a correct ultrasound examination underwent preoperative angiography. After surgical revascularisation, patients with digital gangrene underwent debridement. This was performed in the same surgical session or during the subsequent few days.

Postoperative treatment included low-molecular-weight heparin (LMWH) treatment for 1month, followed by anti-platelet medication alone. This was treated using aspirin, unless the patient was already on other anti-platelet medication (i.e., clopidogrel and ticlopidine).

Postoperatively, patients were followed up at regular intervals at 1, 3 and 6months, and every 6months thereafter. Graft patency was clinically evaluated by the presence of a palpable pulse and by duplex ultrasound. All data were prospectively entered at the time of treatment into a vascular registry (Microsoft^® Access^® and Excel^®, Redmond, WA, USA), and the registry updated periodically with patient follow-up information. Data included demographics, indications for surgery, co-morbid conditions, specific operative details, complications and outcomes. A retrospective query of the database and chart reviews were done for this study. Demographic and clinical characteristics of the study population are reported as the mean, range and percentage values. Statistical analysis was performed using the Statistical Package for Social Sciences version 12 SPSS^® (SPSS Inc., Chicago, IL, USA) statistical software. Graft primary and secondary patency and limb salvage were determined with the Kaplan–Meier life table method.

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3. Results 

From January 1998 to January 2008, 23 bypasses were performed on the brachial or infrabrachial artery in 23 patients. The mean age was 58years (range, 19–76years), with 13 male and 10 female patients (43.4%).

Concomitant diseases included: coronary artery disease in five (21.7%) patients, hypertension in six (26%), end-stage renal disease in nine (39%), diabetes in 11 (47.8%) and atrial fibrillation in two patients (8.6%) (Table 1).

Table 1. Patient demographics.

ESRD, end-stage renal disease.

Indications for bypass included exercise intolerance in four patients (17%), rest pain in nine (39%) and tissue loss in 10 (44%) (Table 2).

Table 2. Indications for revascularization.

Five patients (22%) were scheduled for surgery after a previous endovascular procedure.

Angioplasty without stent implantation was previously performed on the brachial artery in one patient, on the radial artery in three and on the ulnar artery in one; with restenosis in three patients and occlusion in the other two patients. The mean time from the endovascular procedure to surgical revascularisation was 32days (range: 26–40days).

The aetiology of ischaemia was atherosclerosis in 17 patients (74%), complications of iatrogenic trauma in four patients (17.4%) and chronic ischaemia after embolic events in two patients (8.6%).

The brachial artery was used as the inflow source in 14 patients (60.8%), the axillary in two (8.6%), the radial artery in two (8.6%), the subclavian in four (17.4%) and the common carotid artery in one patient (4.3%).

Outflow arterial targets were: the brachial artery in seven patients (30.4%), the radial artery in 10 (43.4%), the ulnar artery in three (13%) and the deep palmar arch in three patients (13%).

Biological conduits were used in all patients except one. The conduits used were: the great saphenous vein (GSV) in 16 (70%) cases, an arm vein in three (13%), the bovine mesenteric vein (BMV) (Hancock Jaffe Laboratories, CA, USA) in three (13%) and polytetrafluoroethylene (PTFE) (W.L. Gore & Associates, Inc. Flagstaff, AZ, USA) in one case (4%) (Table 3).

Table 3. Patient information.

Pt	Sex	ESRD	DM	Aetiology	Symptoms	Inflow	Outflow	Conduits	Follow-up
1	F	Yes	Yes	Chronic	Hand gangrene; rest pain	Brachial	Radial	Saphenous	36m PP
2	F	Yes	Yes	Chronic	Fingers necrosys; rest pain	Radial	Deep palmar arch	Saphenous	120m PP
3	F	Yes	Yes	Chronic	Ulcer phalanx	Brachial	Radial	Saphenous	12m PP (dead)
4	M	No	No	Chronic	Rest pain	Axillary	Brachial	Saphenous	48m PP
5	F	No	No	Chronic	Hand rest pain	Brachial	Radial	Saphenous	1m PP
									Occlusion
6	F	No	No	Chronic	Hand rest pain; paresthesia	Carotid	Brachial	Saphenous	104m PP
7	F	No	No	Chronic	Rest pain; fingers paresthesia	Subclavian	Brachial	Saphenous	36m PP
8	M	Yes	No	Chronic	Hand rest pain	Brachial	Deep palmar arch	Saphenous	36m PP
9	M	No	No	Trauma	Hand rest pain, Fingers paresthesia	Subclavian	Brachial	Saphenous	96m PP
10	M	No	No	Chronic	Hand rest pain	Subclavian	Brachial	PTFE	1m PP
									24m SP
11	M	No	No	Trauma	Exercise intolerance	Axillary	Brachial	Saphenous	47m. PP
12	F	Yes	Yes	Chronic	Fingers gangrene	Brachial	Radial	Saphenous	47m PP
13	F	Yes	No	Chronic	Rest pain; fingers paresthesia	Brachial	Radial	Bovine mesenteric vein	23m PP
14	M	Yes	Yes	Chronic	Fingers necrosys	Brachial	Ulnar	Bovine mesenteric vein	1m PP
									36m SP
15	M	No*	Yes	Chronic	Hand rest pain	Brachial	Radial	Bovine mesenteric vein	23m PP
16	M	No	No	Chronic	Fingers rest pain; finger necrosys	Brachial	Radial	Saphenous	18m PP
17	M	No	Yes	Chronic	Fingers paresthesia	Subclavian	Brachial	Saphenous	14m PP
18	M	No	No	Trauma	Fingers paresthesia; exercise intolerance	Brachial	Radial	Saphenous	14m PP
19	F	No	No	Trauma	Fingers paresthesia; exercise intolerance	Brachial	Radial	Saphenous	13m PP
20	M	No	Yes	Chronic	Fingers necrocis	Radial	Deep palmar arch	Basilic vein	12m PP
21	M	Yes	Yes	Chronic	Purulent phalanx ulcers	Brachial	Radial	Cephalic vein	12m PP
22	F	No	Yes	Chronic	Distal-middle phalanx necrotic	Brachial	Ulnar	Cephalic vein	3m PP
									Occlusion
23	M	No	Yes	Chronic	Hand rest pain; finger necrocis	Brachial	Ulnar	Saphenous	12m PP

Pt, patient; ESRD, end-stage renal disease; DM, diabetes mellitus; PTFE, polytetrafluoroethylene; m, months (time interval); PP, primary patency; SP, secondary patency.

Intra-operative angiography was performed with standard contrast agents in two patients (9%) with extensive arterial calcification. Preoperative duplex ultrasound was used in all of the other 21 patients (91%).

There were no perioperative deaths, no perioperative cardiac complications, no postoperative wound infection or limb loss and no incidence of postoperative pulmonary or renal failure in this series of upper limb bypass patients.

Minor amputations were performed during the same surgical session for eight patients (35%) with digital gangrene. For three other patients (13%), minor lesion debridements were performed 2–3days after revascularisation. The mean length of postoperative hospitalisation was 6days (range: 4–7days).

The mean 34months’ follow-up was 96% complete, with one patient lost at 18months (Table 3). Life table analysis revealed a primary patency of 82.6% (standard error (SE) 10.02; 95% confidence interval (CI) (75.05–114.33)) and a secondary patency of 91.3% (SE 8.6%; 95% CI (89.24–120.84)). Limb salvage was 100% (Fig. 1).

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• Figure 1 

  Life table of primary and secondary patency.

During the follow-up period, four patients sustained graft occlusion:

(1)The first patient was a 38-year-old patient with a heavy history of drug abuse and previous arterial injection of heroin. He had chronic upper limb ischaemia, with severe arterial disease. He was revascularised using GSV. Occlusion after 7days was unresponsive to further surgical management (Table 3, patient 5).

(2)The second patient was 76years old with peripheral lower limb arterial disease and ischaemic heart disease. He was revascularised using a PTFE graft (6mm in diameter, 18cm in length) due to the lack of autogenous venous conduits and the unavailability of BMV or other biological substitutes in our institution at that time. Bypass occlusion after 30days was successfully treated by thrombectomy. The bypass was patent at the 24-month follow-up control (Table 3, patient 10).

(3)The third patient was a 58-year-old man with end-stage renal disease on chronic haemodialysis, with previous lower limb revascularisation. He was revascularised using a BMV prosthesis (6mm in diameter, 12cm in length) due to lack of autogenous venous conduits. He had bypass occlusion 15days after surgery, successfully treated by thrombectomy. The bypass was still open at the 36-month follow-up control (Table 3, patient 14).

(4)The fourth patient was a 37-year-old woman affected by type 1 diabetes and thrombophilia (factor V disease). She had occlusion of a brachial to ulnar bypass in the cephalic vein, 3months after surgery. Before surgery she suffered griffinclaw hand and distal necrosis. After surgery, she had improvements in her symptoms and in wound healing after debridement. This improvement remained stable even after bypass closure. The patient is regularly followed up in our outpatient clinic, 12months after surgery. She had prostacyclin treatment and enjoys a better motility status, with no further tissue loss (Table 3, patient 22).

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4. Discussion 

Upper limb arterial revascularisation is not a frequently performed operation, accounting for approximately 4% of all vascular surgical procedures.¹, ² This type of surgical treatment was first reported by Garret in 1965.⁷ Since then, only a few other studies have reported on this treatment, and usually on small numbers of patients (Table 4).

Table 4. Summary of the major literature references on this subject.

Author, date, journal, country of publication, study type	Patient group	% of gangrene	Key results	Comments
Spinelli F et al. (present work), Italy, retrospective study	23 patients treated between 1998 and 2008	35	Primary patency:	Surgical bypass treatment
			82.6% (1–3years)
			Secondary patency:
			91.3% (1–3years)
			Limb salvage:100%
Hughes K et al. (2007), J Vasc Surg,9 USA, retrospective study	20 patients treated between 1990 and 2003	15	Primary patency:	Surgical bypass treatment
			85% (1–3years)
			Secondary patency:
			85% (1–3years)
			Limb salvage:100%
Chang BB et al. (2003), J Vasc Surg,4 USA, retrospective study	18 upper extremities treated in 15 patients between 1992 and 2002	83	Primary patency:	Surgical bypass treatment
			88.8% (3–40months)
			Secondary patency:	All patients with end-stage renal disease
			88.8% (3–40months)
			Limb salvage: 88.8%
Roddy SP et al. (2001), J Vasc Surg,8 USA, retrospective study	61 upper extremities treated in 56 patients between 1986 and 1998	13	Primary patency:	Surgical bypass treatment
			87% (1–140months)
			Secondary patency:
			98% (1–140months)
			Limb salvage:100%
Ferraresi R et al. (2006), Circulation,12 Italy, case-control study	1 patient	Necrotic skin lesion with soft tissue infection and osteomyelitis of the distal part of the fourth finger	Amputation of one finger	Endovascular treatment
	Age: 62years
	Gender: M		8-month follow-up
	History: insulin-dependent type II diabetes mellitus and chronic renal failure
Cremonesi A et al. (2009), Eur J Vasc Endovasc Surg,13 Italy, case-control study	1 patient	painful ulcerated ischaemic lesions of the right hand fingers	The 6-month angiographic follow-up showed focal restenosis treated by redo balloon angioplasty	Endovascular treatment

As noted also by Roddy et al.⁸ and by Hughes,⁹ unique demographic differences exist between upper and lower limb bypass populations. Patients with upper limb reconstruction typically present at a relatively early age (mean age of 58 in our study).

In our series of patients, the aetiology was atherosclerosis in 17 patients (74%), of which nine (39%) had concomitant end-stage renal disease. In those patients with end-stage renal disease, distal anastomoses were performed on very calcific and hard to handle ulnar and radial arteries. Clamping of those arteries was achieved using a distal manual clamp, or using an intra-arterial shunt, as previously described by our group.¹⁰

Duplex ultrasound can be used in preoperative evaluation, as previously reported in other studies, due to the ability to locate a complete map of vessels in 89% of the cases.¹¹ In fact, in our series of patients we used duplex ultrasound scan in all the patients, except for two (8.6%) with end-stage renal disease. In those two cases, we used arteriography with standard contrast agents due to extreme arterial calcification, making useless the duplex ultrasound scan. For the same reason, it was necessary to perform a post-procedure arteriography.

The indication for surgery in our series was tissue loss for 44% of the cases. This specific indication has been more frequent than in other reported series. Roddy et al.,⁸ in their study, performed bypass grafts in patients with exertional arm pain in 30%, with rest pain in 57% and with tissue loss in 13% of patients. Hughes et al.⁹ performed bypass grafts in patients with exertional arm pain in 55%, with rest pain in 30%, and with tissue loss in 3% of patients. This difference in indication for surgery is probably due to the fact that, in our institution, we usually treat patients with exertional arm pain using infusional vasoactive therapy for remission of symptoms, while surgical treatment is used for more severe conditions. In the presence of finger gangrene (44% of patients), we preferred to revascularise the arm arteries distally at the wrist level. In three cases, the distal anastomosis was completed on the deep palmar arch. The rationale of this strategy is to increase collateral circulation as close as possible to the necrotic area, with the aim of improving wound healing. Usually arm involvement is a consequence of extremely diffuse arterial disease.

Regarding the surgical technique, we believe that an appropriate conduit is critical for the success of the revascularisation. We used GSV in 16 patients. In patients with lower limb artery disease, when GSV was previously used for leg revascularisation, other conduits had to be chosen. The cephalic and the basilic veins represent an alternative. However, their use may carry some technical difficulties because of the presence of ectasia or lesions from previous infusional therapy in need of repair. With the aim of having better exposure during vein harvesting, we usually use a complete incision of the forearm. This technique is more invasive than the ‘bridge cutaneous procedure’; however, we believe it may help to reduce vein injuries during harvesting.

In three patients (13%) affected by end-stage renal disease BMV was used, due to the absence of suitable autogenous venous conduits both in the lower and in the upper limbs.

In another patient, we used a PTFE prosthesis. This patient had graft thrombosis, necessitating further surgery.

Endovascular treatment is often proposed for chronic limb ischaemia. Concerning its role in the distal upper limbs, we should emphasise that five of the 23 patients had a previous angioplasty without good results.

Results of endovascular treatment on the distal upper limbs are still controversial.

There are not, at the moment, any large reported series with a long follow-up on the endovascular treatment of radial or ulnar arterial chronic ischaemic disease. At the present time, there are only case reports or small case series on endovascular treatment of this district.¹², ¹³ We think that endovascular techniques in the subclavian district can be useful in the treatment of proximal segments, whereas for distal segments further investigations are needed. This is in line with a recent report showing that endovascular treatment for cases of chronic ischaemia in the upper limb was associated with more complications as compared with an open surgical approach.¹⁴

In patients with upper limb ischaemia, a cervico-dorsal sympathectomy is often proposed to heal toe ulcers, alone or in addition to a bypass. We do not have personal experience with this surgical approach. However, we believe this could be useful when associated with revascularisation for upper limb ischaemia. Both the traditional open sympathectomy and minimally invasive endoscopic transthoracic techniques have been used.¹⁵ However, it should be considered that complications have been reported with dorsal sympathectomy. The most frequent complications are represented by Horner's syndrome, pneumothorax and haemothorax. More serious cardiovascular complications have been reported as well,¹⁶ especially after bilateral treatment. For this reason it has been suggested that patients should be carefully questioned concerning possible vagal symptoms before undertaking cervico-dorsal sympathectomy.

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5. Conclusions 

In conclusion, surgery for upper limb chronic ischaemia is an infrequent treatment. Endovascular treatment of the upper limb distal district has not been widely reported in the literature. Nevertheless, in our experience, endovascular procedures have not produced good results. We believe bypass surgery represents a valid treatment in this clinical setting, both for limb salvage and for relief of symptoms.

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6. Conflict of Interest 

The authors have no conflict of interest to disclose.

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