Peripheral Vascular Surgery Society

#13. DISTAL FOREARM AND PALMAR BYPASSES FOR HAND GANGRENE IN PATIENTS WITH END-STAGE RENAL DISEASE: IS IT WORTHWHILE?

Luis A. Sanchez, MD, Teresa Benaquista, MD, Berish Strauch, MD, William D. Suggs, MD, and Frank J. Veith, MD

Montefiore Medical Center, Bronx, NY

Upper extremity ischemia and gangrene are rare and account for about 1-2% of all peripheral vascular procedures performed. It is usually due to a variety of autoimmune conditions and occasionally atherosclerosis. However, hand ischemia and gangrene have been reported with increasing frequency in patients with end-stage renal disease (ESRD) due to the complications of hemodialysis access procedures and, less frequently, due to the unique progressive pathological changes in their arterial walls. Arterial bypasses to the distal forearm and palmar vessels are rarely performed but are sometimes the only option to salvage a functional hand in these patients.

Over the past 4 years we performed 6 arterial bypasses to the level of the wrist or hand for limb salvage in patients with ESRD. The group included 5 men and 1 woman (5 on hemodialysis and 1 on peritoneal dialysis) who presented with progressive hand gangrene. One patient had a functioning radio-cephalic fistula associated with distal occlusive disease, while the other 5 patients had progressive distal arterial occlusive disease. All patients underwent successful vein bypasses with a variety of conduits (3 with greater saphenous vein, 2 with cephalic vein, and 1 with lesser saphenous vein). Three by0passes were performed to the distal radial artery at or distal to the wrist, 2 to the palmar arches, and 1 to the distal ulnar artery. There were no perioperative mortalities or significant morbidity. All bypasses were patent with associated salvage of a functional hand at a mean follow-up of 14 months. Three patients have died of cardiac complications at a mean follow-up of 17 months.

Hand ischemia and gangrene is increasingly prevalent as the number of patients with ESRD continues to grow. Standard vascular and microvascular techniques can be successfully used to perform bypasses to the level of the wrist and hand in these patients to safely and effectively maintain hand function and avoid upper extremity amputations in a selected group of patients.

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Last updated January 1,2000