Treatment of Vascular Disorders of the Hand Flashcards
angiography is the standard study for
vascular imaging.
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The ulnar lies deep to the flexor carpi ulnaris along
its course.
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Because of the distal muscle belly of the flexor carpi
ulnaris, the underlying ulnar artery may be compressed in some
instances and may not be palpable
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The proximal and the distal position of radial artery
t passes through the
interval between brachioradialis and pronator teres proximally
and between brachioradialis and flexor carpi radialis distally
The interosseous arteries and a persistent median artery are possible sources of
secondary collateral blood supply to the hand
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The superficial palmar arch located deep to the palmar
fascia and distal to the deep palmar arch
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There is significant variability
in the superficial palmar arch, which can be described as either complete or incomplete
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a complete superficial palmar arch was
found in 84.4% ofspecimens
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Variant of superficial palmer arch
subdivided into five variants initiated by the ulnar artery with variouscontributions from the superficial
volar branch of the radial artery, the median artery, or communicating branches from the deep palmar arch.
dorsal branch of the radial artery after it has passed dorsally deep to the abductor pollicis longus and extensor pollicis brevis tendons and then returns volarly into the deep palm through the two heads of the first dorsal interosseous
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Before returning volarly, the dorsal
radial artery branch typically gives rise to the dorsal carpal rete
and the princeps pollicis artery.
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As the deep palmar arch crosses the
palm, it passes deep to the flexor tendons distal to the distal carpal row.
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complete deep palmar arch was found in nearly all patients
with anastomoses to one or both deep volar branches of the ulnar
artery in all patients
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the primary venous drainage of the fingers and hand
is through the dorsal veins. These vessels drain into the basilic and cephalic veins in the forearm.
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Allen test to be reliable when compared against Doppler
ultrasonography,
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nail bed
microvasculature evaluation?
Capillaroscopy is a technique using high-powered light microscopy to evaluate the morphology and distribution of the nail bed microvasculature
Visible spectrum evaluation may be augmented
with the use of dynamic fluorescent angiography.
How we can differentiate between primary and secondary Raynaud phenomenon?
assessment of the nail bed capillaries using dynamic fluorescent angiography. the technique is a useful screening tool to
distinguish between patients with primary Raynaud phenomenon (RP) and secondary
Duplex ultrasonography is most useful for providing real-time blood flow evaluation
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Computed tomography angiography is a
rapid and relatively noninvasive vascular imaging modality
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magnetic resonance
angiography, this may be used when it is desirable to avoid ionizing radiation
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the standard for vascular imaging is digital subtraction angiography
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Angiography also permits concomitant interventional procedures
such as intra-arterial delivery of thrombolytics or thrombectomy
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Hand ischemia commonly result following catheterization
F Thrombosis of the radial and ulnar
artery following catheterization may occur, but it rarely results in hand ischemia
In critically ill patients receiving vasopressors, peripheral vasoconstriction may result in digital ischemia in up to 2% of patients
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Creation of an arteriovenous fistula for hemodialysis access may result in decreased blood flow to the hand, but only rarely does it cause ischemic why?
because of a steal phenomenon
Treatment of steal phenomenon
distal revascularization with interval
ligation (DRIL)
Sign of chronic ischemia
Splinter hemorrhages in the nail beds, fingernail changes, or digital ulcers may be a sign of a more chronic etiology
Angiography is the study of
choice to characterize the level ofocclusion, sources ofcollateral flow, and possible proximal sources of emboli
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tissue plasminogen activator often is considered as an
initial treatment in cases of acute
ischemia
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Revascularization procedures should be reserved for cases in which there is a clear site of obstruction that either can be resected and reconstructed or bypassed to a patent distal target
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Isolated deep venous thrombosis of the upper extremity is uncommon
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What is phlegmasia cerulea dolens?
patients with total or near-total thrombotic
occlusion of the deep and superficial veins, they may develop ischemic thrombosis,
Classically, an episode of RP is triggered by cold exposure or emotional stress
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pallor (white) to cyanosis (blue) to reactive hyperemia (red) upon reperfusion. These episodes are associated with paresthesias and burning pain
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What are the most important diagnostic criteria for RP
a diagnosis requires cold sensitivity as a trigger and biphasic color
changes from white to blue during an attack
to cold
sensitivity and biphasic color changes, three of the following seven criteria must be me
- triggers other than cold,
- bilateral involvement,
- associated numbness or paresthesias,
- well-demarcated areas ofinvolvement,
- photographic evidence ofRP supplied by the patient,
- involvement ofareas other than fingers or toes, and
- presence ofthe classic triphasic color changes from white to blue to red.
criteria for diagnosis
ofprimary RP
normal capillaroscopy, no evidence ofsecondary causes or connective tissue disease, and negative or low antinuclear antibody titers.
Secondary RP id painfull
F Unlike in primary RP which is painful
but typically has a benign course, secondary RP often is associated with
significant morbidity including digital ulceration and gangrene
prevalence between M and F
prevalence rates range from I% in men to 30%
in women across various studies
Risk factors included
female gender, family history in
a first-degree relative, smoking, and migraines
mediated by sympathetic alpha-adrenergic innervation
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exacerbated by endothelial cell dysfunction, including increased endothelin-1 activity and decreased nitric oxide activity
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Treatment typically is reserved for patients with
refractory primary RP or with secondary RP.
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Medical treatment
strong evidence supporting the use of calcium channel blockers and iloprost, limited evidence supporting the use of atorvastatin, and conflicting evidence for the use of ketanserin and bosentan
phosphodiesterase-5 inhibitors including sildenafil and tadalafil demonstrated modest improvements in symptoms, duration, and frequency of attacks.
Injection ofbotulinum tox
Surgical treatment with periarterial sympathectomy may be indicated in patients who fail medical management and have persistent
digital pain or ulcerations, particularly in patients with systemic sclerosis
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Surgical tech
(1) disrupt sympathetic tone to the palmar and digital vessels by stripping the periarterial adventitia dividing the nerve of Henle arising from the ulnar artery
(2) perform distal revascularization ifthere is proximal occlusion
(3) debride digital ulcers.
Aneurysms often present as a painless, palpable, pulsatile mass
that occasionally is associated with signs of local nerve compression.
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Ischemia is common with aneurysm
F Ischemia is uncommon unless there is associated thrombosis and embolism
hypothenar hammer syndrome meaning
Traumatic thrombosis of the ulnar artery
How much percentage of patients with RP have Hperthener ulnar syndrome
1.1 % and 1.6% of patients in two separate studies were found
to have hypothenar hammer syndrome
Risk factoe for Hypothenat hammer syndrom
men, smokers, and had occupational or hobby-related exposures to repetitive hand trauma
Patients typically present with unilateral vascular insufficiency to the small, ring, or middle fingers; involvement of the thumb strongly suggests an alternative diagnosis
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In some patients, the small finger
is spared why?
In some patients, the small finger
is spared because of the proper ulnar digital artery to the small finger arises proximal to the Guyon canal
Symptoms
pain, cold
intolerance, and numbness or weakness due to local compression of
the ulnar nerve
Angiography is the standard for diagnosis
of hypothenar hammer syndrome and can be used to rule out more proximal embolic sources
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The pathognomonic corkscrew sign, first
described by Hammond and colleagues,42 is an early sign of chronic
damage to the intima and media leading to progressive fibrosis
with ectasia
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Angiography also facilitates operative planning by defining the level of involvement of the ulnar artery,
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Nonoperative
treatment
behavioral modification, smoking cessation, and medical management with vasodilators and antiplatelet
agents.
83% of patients were treated successfully with
medical management alone
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Rates of surgical intervention for patients presenting
with hypothenar hammer syndrome
range from 17% to 71% in two
separate studies
if there is adequate distal flow with
backfilling into the distal ulnar artery we can ligate the effected segment only
F the defect should be reconstructed with either direct repair if the defect is short enough or
reconstruction with an interpositional vein or artery graft
arterial grafts vs vein graft
are more physiologic and may have improved long-term outcomes.
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Arterial graft donor sites
include the descending branch of the
lateral femoral circumflex artery, deep inferior epigastric artery,
thoracodorsal artery, or subscapular artery
the contralateral radial
artery should not be harvested because of the high incidence of occlusion or ectasia of the ulnar artery seen in the contralateral
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arterial grafts in younger and more active patient populations.is prefered
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nonoperative treatment for hypothenar hammer syndrome, 12% of patients had a complete response to treatment and 70% had a partial response to treatment;
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Buerger disease, also known as thromboangiitis obliterans, is an inflammatory disease of the small- and medium-sized arteries of the upper and lower extremities
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The common risk factors
Tobacco exposure is the primary risk
factor
Discontinuation of tobacco use is the
only definitive treatment.
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bypass and revascularization procedures typically are not successful
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In the management of hypothenar hammer syndrome Fibrinolysis (or thrombolysis) is advocated only for treatment in cases of acute onset of digital ischemia (less than 2 weeks).
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Complications after excision occurred in 22% of slow-flow lesions and 28% of fast-flow lesions
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Glomuvenous malformations (GVMs) commonly present in the middle phalanx
F all GVMs were located
in the distal phalanx and 59% were in the subungual region
presenting symptoms
Patients typically present with a highly focal
point of tenderness, which may be associated with cold intolerance and a bluish discoloration
Clinical examination alone may be
sufficient for diagnosi
T ultrasonography and magnetic
resonance imaging may be used as adjuncts for diagnosis
conservative treatment can work ?
F Surgical excision is the only known treatment, and in a retrospective review of 51 cases ofGVMs treated with excision, there was a 3.9% recurrence rate
Pyogenic granulomas are characterized by a small (typically <l cm), rapidly growing, friable lesion
of the skin or mucosa! surfaces that may be either pedunculated or sessile.
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cryotherapy is better than surgical excision for pyogenic granuloma
F no statistical difference between
the recurrence rates in these groups
surgical excision except where a nonsurgical treatment is preferred such as in cases where the lesion is located near cosmetically sensitive or vital structures.
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the ulnar artery emerges from the Guyon
canal, it is in a relatively superficial and unprotected position on the
superficial aspect of the hamate where it is subject to trauma from
external forces.
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Examination findings may include a pulsatile mass
at the level of the wrist, subungual splinter hemorrhages, ischemic
changes in the fingers, or digital ulceration
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Angiography is the standard for diagnosis
of hypothenar hammer syndrome and can be used to rule out more
proximal embolic sources.
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cryotherapy often
required multiple treatments in the reviewed studies and because
surgical excision allows single-stage treatment with the opportunity
to send the lesion for pathology (Piogenic granuloma)
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