Acs0615 Upper Extremity Revascularization Procedures

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Acs0615 Upper Extremity Revascularization Procedures

  1. 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 1 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES John Byrne, M.CH., F.R.C.S.I.(Gen), Philip S. K. Paty, M.D., F.A.C.S., and R. Clement Darling III, M.D., F.A.C.S. Vascular surgeons are commonly called on to treat patients with years).6 Usually, there is an underlying embolic source (e.g., car- acute arm ischemia. Elective arm revascularization is an infre- diac dysrhythmia). Most arm emboli (75%) are of cardiac origin. quently performed procedure, one that usually prompts surgeons The brachial artery is the most common site of emboli (60% of to resort to reference texts. Even in busier centers, elective arm cases), followed by the axillary artery (26%). In situ thrombosis reconstructions currently account for only 3.2% of elective limb accounts for 5% of episodes of arm ischemia.7 revascularizations. Balloon angioplasty has largely replaced surgi- cal bypass in the treatment of subclavian occlusions; however, the Selection of patients All patients with acute-onset arm very growth of endoluminal approaches to arm revascularization ischemia are candidates for embolectomy. Conservative manage- has led to a paradoxical increase in the need for so-called prophy- ment should be considered only for patients who are terminally ill lactic carotid-subclavian bypass in patients with thoracic aneurysms. or unfit for surgical intervention. In addition, the rising incidence of diabetes and the longer survival times reported in patients with renal impairment have led to Alternative therapy Some authors have achieved good re- increased use of distal bypass procedures in the arm (analogous to sults by using thrombolysis to treat acute occlusion of the axillary pedal bypass procedures in the leg [see 6:17 Infrainguinal Arterial artery or the brachial artery.8 However, in a 2001 series that in- Procedures]). Finally, the growing number of dialysis access proce- cluded 38 patients with 40 occlusions treated with thrombolysis, dures performed has led to an increased incidence of arm ische- the success rate of this approach was only 55%, and eight patients mia resulting from these operations. had to undergo surgical thrombectomy after thrombolysis failed.9 In this chapter, we describe the technical aspects of the proce- Excellent outcomes have also been reported for the treatment of dures employed for emergency and elective arm revascularization. acute arm ischemia with rotational thrombectomy devices (e.g., We also touch on pharmacologic alternatives to elective revascu- Rotarex; Straub Medical, Wangs, Switzerland). To date, however, larization and briefly consider the potential role of minimally inva- no large published studies have evaluated these devices, and clini- sive techniques (e.g., thoracoscopic sympathectomy). cal experience with them is currently limited to case reports.10 Operative Planning Procedures for Acute Arm Ischemia In most patients with acute arm ischemia, diagnosis is straight- Acute arm ischemia accounts for one fifth of all episodes of forward and surgical treatment relatively easy. Some instances of acute limb ischemia. It occurs twice as often in females as in males. acute arm ischemia, however, are caused by an inflow lesion in the Brachial embolectomy is the most common treatment. After suc- subclavian artery (SA) (e.g., from ulcerated plaques, a throm- cessful brachial embolectomy, 95% of patients are symptom free1; bosed SA aneurysm, or an arterial thoracic outlet syndrome). In however, the operative mortality may be as high as 12%.2 Most re- such situations, even a technically perfect embolectomy will fail to ports that address acute arm ischemia include only those patients restore normal hand perfusion. who are treated surgically. In fact, between 9% and 30% of The majority of brachial embolectomies are performed with patients who present to vascular surgeons with acute arm ischemia local anesthesia, with or without monitored conscious sedation. are managed conservatively, either because they are unfit for sur- Operative Technique gery or because they have minimal symptoms.These conservatively managed patients are probably underrepresented in the literature. The origins of the ulnar and radial arteries are exposed by means In the few reported series, assessment of symptoms and disability of a so-called lazy S incision [see Figure 1a], which prevents the has been largely inconsistent. However, in a 1964 series that in- elbow contracture that can occur with a vertical incision. The skin cluded 95 patients, 32% of those who were managed conservative- and the subcutaneous tissues are divided. Care is taken to preserve ly were left with abnormal function in the arm after treatment.3 In the superficial veins, especially the median antecubital vein, which a 1977 report, 75% of the conservatively managed patients had may be needed to patch the brachial artery. The bicipital fascia is poor functional outcomes.4 In a 1985 study, 50% of the conser- incised, and the brachial artery is found between the tendon of the vatively managed patients had persistent forearm claudication.5 biceps laterally and the median nerve medially [see Figure 1b]. The conclusion to be drawn is that although conservative manage- Dissection is continued distally until the ulnar and radial arteries ment is appropriate for some patients with acute arm ischemia, are encountered.The radial artery is a continuation of the brachial every effort should be made to restore blood flow in patients who artery; the ulnar artery comes off the brachial artery medially and, have a reasonable life expectancy. within 2 to 3 cm of its origin, dives beneath the pronator and epitrochlear muscles. It is important to expose the origins of both BRACHIAL EMBOLECTOMY forearm arteries because the embolectomy catheter must be passed down each vessel. If the catheter is blindly passed down the brachial Preoperative Evaluation artery, it will probably travel down the radial artery. Patients with acute arm ischemia tend to be slightly older at pre- An arteriotomy (usually vertical) is made in the brachial artery. sentation than patients with leg ischemia (74 years versus 70 Clot may be encountered at the bifurcation; if so, it is readily
  2. 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 2 a tained a further embolic episode, and all had ongoing atrial fibril- lation.6 Patients are routinely followed up by means of noninvasive studies 4 to 6 weeks after operation. FOREARM FASCIOTOMY b Unlike calf fasciotomies, which are commonly necessary for leg ischemia, forearm fasciotomies are rarely required for acute arm ischemia.They are more commonly required for traumatic injuries to the arm (e.g., crush injuries or supracondylar fractures of the Musculocutaneous Nerve humerus) or for iatrogenic injuries (e.g., inadvertent infusion of fluid into the muscle compartments of the forearm). Forearm fas- Radial ciotomies are immediately effective when they are performed, and Nerve the incisions, though extensive, usually heal quickly. Preoperative Evaluation The forearm muscles are typically tense and tender, though the diagnosis can be difficult to make. One option for assessment is to test compartment pressures with a needle and a transducer; if the intracompartmental pressure is higher than 30 mm Hg, fascioto- Radial Artery my may be indicated. Another option is insonation of the radial and ulnar arteries; if the signal is absent or severely obstructed, fasciotomy may be indicated. Neither of these techniques, howev- er, is reliable. As with lower-extremity ischemia, even the finding Median Nerve of a pulse does not eliminate the need for fasciotomy.The decision whether to perform the procedure is made on clinical grounds.11 The relevant dictum is “If one is thinking about a fasciotomy, it is probably indicated.” Brachial Artery Selection of patients Awareness of the diagnosis is crucial. Bicipital Any patient with the traumatic or iatrogenic conditions previous- Aponeurosis ly mentioned (see above) should be considered to be at risk for compartment syndrome. Ulnar Artery Alternative therapy There is no alternative to fasciotomy. Failure to recognize the problem or undue delay in performing adequate fasciotomies will lead to forearm muscle ischemia and a Volkmann’s ischemia contracture, resulting in a useless hand. Figure 1 Brachial embolectomy. Shown are (a) a lazy S skin inci- sion and (b) the main nerves and vessels exposed. Operative Planning Because this procedure is rarely performed, the surgeon may find it useful to mark the incisions on the skin with an indelible removed. In some cases, the brachial artery is pulseless, which indi- pen before operation. The operation is generally performed with cates that the embolus is lodged more proximally. Once inflow is general anesthesia, but if the patient is profoundly ill, it may be established, a size 2 or 3 embolectomy catheter is passed distally performed with local anesthesia instead. down each forearm artery. The arteriotomy is then closed either primarily or with a vein patch. A segment of vein may be harvest- Operative Technique ed from the antecubital fossa. Adequate flow in the radial and ulnar Both a volar and a dorsal incision are required [see Figure 2]; arteries is confirmed by means of an intraoperative Doppler probe. there is no single-incision option, as there is for leg fasciotomy. On Occasionally, the hand continues to appear ischemic even after the volar aspect of the arm, a curvilinear incision is made to allow an adequate embolectomy. This persistent ischemia is caused decompression of the flexor compartment. Because this compart- either by an unrecognized inflow lesion or by embolization to the ment is supplied by a single vessel (the interosseous artery) and digital arteries that has been occurring over an extended period. lacks any collateral circulation, it is particularly susceptible to In these patients, an arch aortogram with selective views of the ischemia. On the dorsal aspect, a vertical incision is made to affected arm should be performed immediately after operation. release the dorsal compartment. Because of its deep location in the Any lesion in the SA or the innominate artery can be treated with forearm, the median nerve is especially susceptible to compart- angioplasty and stenting. ment syndrome. At the level of the elbow, the bicipital aponeuro- sis is divided so that it can be decompressed. At the wrist, the flex- Postoperative Care or retinaculum is divided in much the same way as in a carpal tun- The mainstay of postoperative management is adequate antico- nel decompression. In severe cases, the deep intramuscular fascia agulation. Embolization recurs after successful embolectomy in enveloping the flexor digitorum superficialis, the flexor digitorum one third of patients if systemic anticoagulation is not instituted. profundus, and the flexor pollicis longus may be opened as well. It may recur even in the face of oral anticoagulation: in a 1989 As a rule, the skin incisions are loosely approximated to facilitate study, 11% of patients given warfarin after embolectomy sus- later closure. In any case, the incisions usually heal very well.
  3. 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 3 Postoperative Care reasons, may not be candidates for endovascular procedures Regular dressings are applied to the area. Often, delayed prima- (e.g., those with an occluded stent and those in whom the anato- ry closure of the fasciotomy sites may be performed once the mus- my is unsuitable). In patients for whom it is indicated, innomi- cle edema has resolved. Further pressure measurements may be nate artery bypass has durable beneficial effects and thus is an performed to confirm that all muscle compartments have been option worth considering, despite its potential for significant released. morbidity. Preoperative Evaluation Procedures for Chronic Arm Ischemia Arm ischemia is the typical presentation for patients with The etiology of chronic arm ischemia is diverse. Although ath- innominate artery occlusion. Cerebrovascular symptoms related erosclerosis is still the major cause, other potential causes (includ- to the vertebral or carotid arteries are the second most common ing thoracic outlet syndrome and iatrogenic injury, as well as rarer presentation. causes such as Takayasu arteritis, giant cell arthritis, and radiation- In many patients, noninvasive imaging yields the first indication induced injury) must also be considered. Initial assessment is car- of innominate artery stenosis. It is difficult, however, to distinguish ried out by means of noninvasive studies (e.g., pulse-volume between an occlusion in the proximal SA and one in the innomi- nate artery on a duplex ultrasonogram. Contrast angiography is recordings [PVRs] and duplex ultrasonography), followed by the gold standard for making this distinction. As with all major magnetic resonance angiography (MRA) or computed tomo- vascular procedures, standard cardiac investigations and clearance graphic angiography (CTA). Confirmation of the findings are mandatory. obtained from these studies may be obtained by means of arch and arm angiography. As a rule, any occlusive lesions found will be Selection of patients Innominate artery bypass is the oper- in the innominate, subclavian, axillary, or forearm arteries. Each ative standard for selected patients with upper-extremity ischemia. location calls for a different treatment stratagem. In patients who are at particularly high risk, however, extrathoracic AORTOSUBCLAVIAN BYPASS AND EXTRATHORACIC options (e.g., carotid-carotid bypass or, rarely, axilloaxillary OPTIONS FOR INNOMINATE ARTERY OCCLUSION crossover grafting) should be considered.We prefer carotid-carotid crossover for higher-risk patients. Cerebrovascular considerations Innominate artery reconstruction is a major surgical proce- (e.g., asymptomatic high-grade lesions [i.e., > 70% occlusion] or dure. In one major series, the reported operative mortality was ulcerated plaques with greater than 50% luminal narrowing) may 5.4%.12 Currently, innominate artery bypass is rarely performed, also warrant intervention. having been largely supplanted by balloon angioplasty and stent- ing. Nevertheless, there are still some patients who, for technical Alternative therapy Indirect or extra-anatomic approaches to innominate artery reconstruction include axilloaxillary crossover grafting, carotid-carotid crossover, and femoroaxillary bypass. In general, these approaches are reserved for higher-risk patients in whom endovascular therapy is not an option. Operative Planning Operative planning must take into account relevant anatomic details. It is important to keep in mind that the anatomy of the aor- Areas of Maximum tic arch is not invariable: in 30% of patients, there are variations in Compression of the arch anatomy that may make innominate artery bypass more Median Nerve difficult.The most common variation is an innominate artery that branches into a right common carotid artery (CCA) and a right SA, with the right CCA and the right SA coming directly off the arch. In 16% of patients, however, the innominate artery and the right CCA may have a common ostium. In 8% of patients, the left CCA comes off the innominate artery, leaving the left SA as the only other artery coming off the arch. In 6% of patients, the left vertebral artery comes off the arch between the left CCA and the left SA. In fewer than 1% of patients, the right SA comes off the descending aorta as the last arch branch, then travels behind the esophagus (as the retroesophageal right SA) to reach the right supraclavicular fossa.13 Operative Technique The innominate artery is approached via a median sternoto- my.14 A sternal retractor is placed and opened. The thymus is divided along its midline with the electrocautery, and the inferior thymic vein is ligated and divided. The brachiocephalic vein is identified as it crosses the innominate artery, then mobilized and Volar Incision Dorsal Incision placed in a vessel sling. The pericardium is opened from the ven- Figure 2 Forearm fasciotomy. Shown are (a) a volar incision tricular surface to a point just below the origin of the innominate and (b) a dorsal incision in the forearm. artery. It is held away from the operative field with stay sutures.
  4. 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 4 Right Common Left recovery, patients are followed by means of noninvasive graft Carotid Artery Brachiocephalic surveillance. Vein Left Common Carotid Artery CAROTID-SUBCLAVIAN BYPASS OR TRANSPOSITION Most patients with SA stenosis or occlusion require no treat- Right ment. In many cases, overt symptoms are absent, and the diagno- Subclavian Artery sis is made serendipitously when a reduced pulse pressure is encountered in one arm. For patients with symptomatic lesions, balloon angioplasty with stent insertion is currently the treatment of choice, having been shown to be a durable and effective thera- py.15,16 Elective bypass is typically reserved for lesions that are not amenable to balloon angioplasty. As stenting of thoracic aortic aneurysms becomes more common, however, stents are increasing- ly being applied across the origin of the left SA to facilitate proxi- mal fixation, which means that a carotid-subclavian transposition or bypass is required to maintain flow.Thus, the growth of endovas- cular surgical treatment of thoracic aortic aneurysms has, paradox- ically, created a growing population of patients who require a carotid-subclavian bypass. It is important, therefore, that this pro- Aortic Arch cedure remain part of the armamentarium of all vascular surgeons. Preoperative Evaluation A healthy CCA is an excellent inflow source for an SA bypass procedure. Before operation, the CCA should be evaluated with duplex ultrasonography, supplemented by arteriography. Aortic arch anomalies (e.g., the presence of a bovine aortic arch) should be identified. In patients with contrast allergies or renal impair- ment, MRA may be employed. In the future, CTA may prove to be the modality of choice. Figure 3 Innominate artery bypass. One end of the graft is sewn to the aorta in an end-to-side fashion, and the other is sewn to the Selection of patients It is important to confirm that arm common ostium of the right SA and the right CCA in an end-to- symptoms are in fact caused by subclavian disease. In young end fashion. patients, the possibility of thoracic outlet syndrome should be con- sidered. In older patients, the differential may include cervical disc problems or osteoarthritis. In patients with thoracic aortic The ascending aorta is then exposed. Fat and visceral pericardium aneurysms, our threshold for treatment is a diameter of 5 cm. are cleared from the anterior and lateral walls of the aorta to allow Given the complexity of the anatomy and the potential for nerve placement of a partial exclusion clamp. injury, some surgeons are reluctant to perform carotid-subclavian The brachiocephalic vein is retracted downwards, and dissec- bypass or transposition, instead favoring axilloaxillary crossover tion is continued distally along the innominate artery toward the grafting. However, axilloaxillary crossover has a lower patency rate origins of the right SA and the right CCA. Care must be taken to than carotid-subclavian bypass or transposition, and its subcuta- keep from injuring any major nerves, particularly the right recur- neous placement and prominence make it less acceptable to most rent laryngeal nerve. patients. In addition, instances of erosion through the skin have Some authors have employed a partial median sternotomy been reported. approach to the innominate artery, which is useful when access to the distal half of the innominate artery is required and access to Alternative therapy Subclavian artery balloon angioplasty the ascending aorta is not required. The advantage of this is less invasive than surgical bypass and is a durably effective pro- approach is that it preserves the lower sternum, thereby enhancing cedure that is well tolerated by most patients.17 However, patients the stability of the chest and reducing postoperative pain.The inci- who have recurrent stenosis or whose lesions are too close to the sion extends only to the fourth intercostal space. vertebral arteries may not be candidates for angioplasty. For such After heparinization, a partial exclusion clamp is placed on the patients, prosthetic bypass or reimplantation of the subclavian ascending aorta, and an arteriotomy is made. An 8 mm graft is artery is an ideal option. The temptation to perform a lesser pro- sutured to the aorta in an end-to-side fashion with 3-0 or 4-0 cedure (e.g., axilloaxillary bypass) should be resisted. polypropylene. If the innominate artery is occluded, the right Operative Planning CCA and the right SA are clamped, and the innominate artery is divided and oversewn. The graft is then sewn to the common The two key considerations in the planning of the operation are ostium of the SA and the CCA in an end-to-end fashion [see (1) whether to perform a bypass or a transposition and (2), if a Figure 3]. Flow is confirmed with a Doppler probe, as with all the bypass is chosen, whether to use autologous vein or synthetic reconstructions we describe in this chapter. material as the conduit. For a bypass, prosthetic grafts, being short and of large caliber, are generally considered preferable to autolo- Postoperative Care gous vein grafts18,19: they are less likely to become kinked or give After the operation, patients are observed in the intensive rise to intrinsic disease, and the long-term patency of prosthetic care unit. In general, anticoagulation is not indicated. After reconstructions is excellent.
  5. 5. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 5 Transposition of the SA is an excellent alternative to carotid- constructed. The CCA is mobilized so that once two straight vas- subclavian bypass, with long-term patency rates approaching cular clamps are placed and rotated anteriorly, the graft-CCA 100%.20 Preoperative consent should include acknowledgment of anastomosis may be performed more easily. Once the bypass has the potential for injury to the phrenic nerve or the brachial plexus. been completed, flow is restored—first to the arm, then to the proximal SA, and finally to the distal CCA, so as to minimize the Operative Technique carriage of embolic debris to the brain. Flow should then be The patient is placed in the supine position, with a towel roll assessed with a pencil Doppler probe. placed between the scapulae. The neck is tilted toward the con- After completion of the bypass, the scalene fat pad is tacked to tralateral shoulder. A transverse incision is made 1 cm superior to its former medial and inferior attachments; failure to do so may the clavicle.The underlying platysma and the lateral portion of the leave a visible defect in this area. The wound is drained with a sternocleidomastoid muscle are divided in the line of the incision. closed suction apparatus. An upright chest x-ray is obtained to rule The underlying omohyoid muscle and the external jugular veins out pneumothorax or hemidiaphragmatic elevation secondary to are divided, and the scalene fat pad is mobilized and retracted lat- phrenic nerve injury. Postoperative evaluation of bypass patency is erally and cephalad. Minor lymphatic vessels are identified and li- accomplished by physical examination with palpation of pulses at gated. The internal jugular vein is visible medially in the carotid the wrist. Further objective documentation of patency is obtained sheath, and the carotid artery is usually situated posteriorly. Every by means of PVRs, duplex ultrasonography, or both. effort should be made to keep from injuring the vagus nerve and Postoperative Care the thoracic duct on the left; the risk of thoracic duct injury may be minimized by not dividing the lymphatic tissue lying between The major postoperative complication is phrenic nerve injury the phrenic nerve and the lateral border of the internal jugular and resulting paralysis of the hemidiaphragm [see 4:6 Paralyzed vein. The anterior scalene muscle is divided as far caudad as pos- Diaphragm]. Another significant complication is lymphatic leakage, sible to reveal the SA; care must be taken to avoid the overlying which may occur as a result of either minor or major duct injury. phrenic nerve, which courses diagonally in a lateral-to-medial Adequate wound drainage and prompt recognition of the lymphat- direction along the anterior surface of the muscle. ic leak are the keys to management. Minor leaks usually seal with A bypass from the CCA to the SA is then performed in an end- adequate drainage. If drainage is excessive, the patient will have to to-side fashion with a 6 mm or 8 mm prosthetic graft [see Figure be maintained on parenteral nutrition with a formula that includes medium-chain triglycerides. On occasion, thoracic duct ligation via 4]. The graft is usually tunneled under the internal jugular vein. thoracotomy or thoracoscopy may be necessary. Other complica- Often, the graft-SA anastomosis is constructed first. A clamp is tions include pneumothorax, brachial plexus injury, and stroke. placed on the proximal graft, and the anastomosis to the CCA is Patients are followed with serial PVRs of the arm and duplex ultrosonography of the grafts. Vertebral Inferior Superficial Thyroid Cervical AXILLOBRACHIAL BYPASS Artery Phrenic Artery Artery Left Nerve Axillobrachial bypass may be performed to treat severe occlu- Common sive disease in the axillary or proximal brachial arteries. It is infre- Carotid Artery Suprascapular Artery quently performed for chronic ischemia and more frequently per- formed for shoulder trauma. In the latter setting, it is often associ- ated with brachial plexus injuries. Preoperative Evaluation Axillobrachial bypass is not commonly performed on an elec- tive basis. The axillary and proximal brachial arteries seem to be remarkably impervious to the effects of systemic atherosclerosis. In those rare cases in which this procedure is indicated, preoperative evaluation of the affected arm with selective angiography is appro- priate.Vein mapping should be performed. It is important to con- firm that the patient’s symptoms derive from arm ischemia and not from other conditions (e.g., neuropathy). Alternative therapy If arm ischemia is truly symptomatic at this level, sympathectomy may be considered [see Alternative Therapies for Chronic Arm Ischemia, below]. Angioplasty may be an option for axillary artery lesions, but it is infrequently per- formed in this setting, and data on its effectiveness and durability are relatively sparse. Left Subclavian Artery Operative Planning Autogenous vein is the conduit of choice for axillobrachial bypass. Left Subclavian Vein Prosthetic bypasses have lower patency rates than venous bypasses Figure 4 Carotid-subclavian bypass. One end of the graft is sewn in this setting and should therefore be avoided.The greater saphe- to the left SA in an end-to-side fashion, and the other is sewn to nous vein is the preferred source of the venous conduit, though the the left CCA in an end-to-side fashion. use of the cephalic vein in situ has also been described.
  6. 6. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 6 Axillary Vein Axillary Artery Saphenous Vein Graft Brachial Artery Pectoralis Major Figure 5 Axillobrachial bypass. Shown is the completed bypass, with the greater saphenous vein tunneled subcutaneously. Operative Technique within the sheath. It is gently mobilized and retracted to afford The patient is placed in the supine position, and the arm is access to the brachial artery. Any venous branches that cross the draped circumferentially. A previously mapped leg is draped in artery should be divided carefully, and every effort should be preparation for vein harvesting. The axillary artery is approached made to keep from injuring the posteriorly located ulnar nerve. via a transverse incision placed 2 cm below the middle third of the In contrast, the distal third of the brachial artery and its bifur- clavicle. The underlying pectoralis major is divided in the line of cation are exposed in the antecubital fossa. A lazy S or sigmoid the decussation between its sternocostal and clavicular portions. incision [see Figure 1a] is made to expose the brachial artery while Despite the assurances of most operative texts, the decussation is avoiding wound contracture. The bicipital aponeurosis is then not always readily apparent. Division of the pectoralis major incised to expose the brachial artery, which is sandwiched exposes the clavipectoral fascia, which is then divided.The axillary between the biceps tendon laterally and the median nerve medi- artery is identified cephalad to the axillary vein and is carefully dis- ally. Further dissection exposes the origins of the ulnar and radi- sected, with care taken not to injure the surrounding branches of al arteries. the brachial plexus. The second part of the axillary artery is After systemic heparinization, the venous conduit is harvested, exposed by dividing the pectoralis minor. and its side branches are ligated with fine polypropylene suture lig- If necessary, the distal third of the axillary artery may be exposed. atures or silk ties.The vein is distended with a solution containing An oblique incision is made along the lateral margin of the pec- dextrose 70 (500 ml I.V.), heparin (1,000 U), and papaverine (120 toralis major with the arm abducted 90° relative to the thorax. Once mg).The excised conduit may be employed in either a reversed or the subcutaneous tissue is divided, the axillary sheath is located near an orthograde (nonreversed) orientation, depending on the taper the posteroinferior border of the coracobrachialis. Care should be of the conduit. If the orthograde orientation is used, the proximal taken to keep from injuring the medial and lateral cords of the anastomosis is performed, the conduit is distended, and the valves brachial plexus medially and the median and ulnar nerves laterally. are lysed with a retrograde Mills valvulotome. In either case, the By preference, bypasses originating from the axillary artery are conduit is tunneled anatomically wherever possible; in this way, it tunneled anatomically along the axis of the axillary and brachial will be less prone to movement, distraction, or distortion. After arteries. Alternatively, they may be positioned subcutaneously; tunneling, the distal anastomosis is constructed [see Figure 5]. however, subcutaneous bypasses are more susceptible to distrac- Immediately upon completion of the bypass, patency and aug- tion injuries caused by forcible abduction of the shoulder. Accord- mentation of flow are assessed with a pencil Doppler probe. ingly, some degree of redundancy should be built into a subcuta- Major potential complications include injuries to the brachial neous bypass. plexus, the median nerve, or the ulnar nerve. Such injuries usual- The middle or the distal portion of the brachial artery is ly are caused by traction and may be minimized by careful dissec- exposed as necessary.The proximal or the middle third of the ves- tion during operative exposure.The median and ulnar nerves and sel is exposed by making a medial incision over the bicipital the brachial plexus are also vulnerable to direct thermal injury; groove, with care taken to keep from injuring the basilic vein and accordingly, dissection with the electrocautery should be avoided. the cutaneous nerves located within the subcutaneous tissue. Postoperative Care Traction on or transection of the median antebrachial cutaneous nerve may lead to hyperesthesia or anesthesia along the medial Postoperatively, the patency of the bypass is documented by dorsal surface of the forearm; these problems occasionally occur surveillance with noninvasive studies. In general, duplex ultra- after dialysis access procedures (e.g., basilic vein transposition) sonography is valuable for determining the patency of the recon- and can be highly debilitating, sometimes even rendering the fis- struction and for detecting any early flow abnormalities in the tula unusable. The brachial sheath is then incised longitudinally. venous conduit. Graft infection should be watched for and appro- The median nerve is the most superficial structure encountered priately treated if found.
  7. 7. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 7 DISTAL REVASCULARIZATION–INTERVAL LIGATION AND REVISION USING DISTAL INFLOW smaller distal artery as the inflow source, RUDI lengthens the fis- tula and preserves antegrade flow in the brachial artery. The rising incidence of diabetes in the United States has led to Of the two options, DRIL is better established and more wide- a corresponding rise in the number of patients in whom vascular ly used at present. It is our preferred option and thus is the prima- access is required for hemodialysis.21,22 As reconstructions become ry focus of the ensuing description. Nevertheless, there are aspects more complex, these patients are increasingly coming under the of the DRIL procedure that many vascular surgeons find counter- care of vascular surgeons. An unfortunate consequence of the intuitive—namely, the ligation of a healthy artery and the bypass- growing number of upper-arm fistulas is that the incidence of dial- ing of a normal arterial segment with a venous conduit.There does ysis-associated steal syndrome (DASS) is increasing as well. DASS seem to be a good argument in favor of RUDI. Long-term evalu- is rare after Cimino or radiocephalic fistula procedures,23 but it ation of this procedure is awaited. occurs in 6% to 8% of patients who undergo upper-arm brachial Preoperative Evaluation artery–based fistula or graft procedures.24,25 DASS may present in either an acute form (characterized by severe rest pain and obvi- Preoperative evaluation for DRIL should follow the same pat- ous ischemia developing within 24 to 48 hours after operation) or tern as that for any elective procedure performed to treat arm or a chronic form (characterized by symptoms and signs developing leg ischemia. Preoperative angiography is performed with vein several weeks or even months after the original operation), each of mapping to identify an adequate source of a venous conduit. which is managed in its own distinct fashion. Cardiac clearance is obtained. In cases of acute ischemia that develops within 24 to 48 hours after an upper-arm fistula procedure, the fistula should be ligated Selection of patients DRIL is generally reserved for patients to restore flow down the native arteries. In cases of chronic with chronic arm ischemia in whom a fistula has been established ischemia, however, the aim is to preserve the fistula and avoid li- that must be preserved. If the option of creating a new fistula in gation.To this end, there are two main surgical options that should the other arm is available, DRIL is probably a less appropriate be considered. The first option is distal revascularization–interval choice than simply ligating the original fistula. ligation (DRIL), which involves the creation of a venous bypass from the proximal portion of the brachial artery to the distal por- Alternative therapy Besides simple ligation of the offending tion of the vessel [see Figure 6].The brachial artery distal to the ori- fistula, which is an option that should always at least be considered gin of the fistula is ligated, flow to the distal arm is restored, and in these patients, there are two techniques that deserve mention as the fistula is preserved.26 The second option is revision using dis- alternatives to DRIL. The first technique is aimed at preventing tal inflow (RUDI), which involves ligation of the fistula at its ori- steal from an upper-arm fistula (always a laudable aim). In this gin, followed by reestablishment of the fistula by means of a technique, the fistula is formed by extending the cephalic vein or venous bypass from the radial or the ulnar artery.27 By using a the basilic vein down the arm and anastomosing it to the proximal ulnar artery or the radial artery just below the brachial bifurcation so as to preserve part of the blood supply to the hand. The medi- Brachial a b Artery an cubital vein may also be used.28 Brachial The second technique is RUDI [see Figure 7]. This procedure Artery differs from DRIL in that it is the fistula, not the native arterial Vein supply, that is placed at risk by the surgical revision, so that in Saphenous the event of graft failure, the fistula is lost but the arm is not Vein Graft endangered. Operative Planning Fistula We do not use prosthetic grafts for this procedure; we prefer to use autogenous vein for the graft, usually a segment of the greater Cephalic or Basilic Vein saphenous vein from the leg. As a rule, the operation is performed with the patient under general anesthesia. Ulnar Ulnar Operative Technique Artery Artery Radial A vertical incision is made in the upper arm at the level of the Artery proximal brachial artery. The skin and the subcutaneous fat are Radial divided, and the proximal brachial artery is sharply dissected free. Artery The portion of the brachial artery distal to the origin of the fistu- la is also dissected free. An adequately long segment of vein is obtained and prepared. Anticoagulation is initiated, and a proxi- mal end-to-side anastomosis is fashioned with 6-0 polypropylene. The vein graft is tunneled subcutaneously, and a distal end-to-end Pre-DRIL Post-DRIL anastomosis to the distal brachial artery is created. Some surgeons prefer an end-to-side distal anastomosis with ligation of the Figure 6 Distal revascularization–interval ligation (DRIL). In brachial artery proximal to the anastomosis. Adequate flow is con- patients with a brachial artery–based fistula (a), chronic ischemia may develop weeks or months after the procedure. The best estab- firmed by means of intraoperative Doppler ultrasonography. lished surgical treatment option is DRIL (b), which preserves the Postoperative Care fistula by creating a venous bypass between the proximal brachial artery (above the origin of the fistula) and the distal brachial Postoperative anticoagulation is generally not warranted; how- artery. ever, a postoperative graft surveillance protocol is initiated. If the
  8. 8. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 8 a b consideration. Vascular reconstruction offers a chance to gain Brachial both. The alternative to attempted arm salvage is amputation. Brachial Artery Artery Selection of patients At our institution (Albany Medical Oversewn Center), all patients with rest pain, digital necrosis, or nonheal- Cephalic or or Ligated ing ulcers are evaluated for possible palmar artery reconstruc- Basilic Vein Fistula tion, provided that they are surgical candidates. Reconstruction is feasible in approximately half of the patients who have renal disease or diabetes. Fistula Cephalic or Alternative therapy Sympathectomy, in various incarna- Basilic Vein tions, has been employed in the treatment of hand ischemia. Ulnar Artery Isolated reports of success notwithstanding, the experience of most vascular surgeons with sympathectomy in this setting has not Radial been favorable. Artery Ulnar Artery Operative Planning Fortunately, exposure of the palmar vessels beyond the wrist is Saphenous not as difficult as might be imagined [see Operative Technique, Vein Graft below]. Nevertheless, because hand bypass procedures are relative- ly new territory for many vascular surgeons, operative planning may benefit from a brief review of the normal anatomy.The hand Radial Artery is supplied with blood by the superficial and deep palmar arches. The superficial palmar arch is supplied by a branch of the radial Pre-RUDI Post-RUDI artery and by the ulnar artery. The deep palmar arch is supplied Figure 7 Revision using distal inflow (RUDI). Another option by the radial artery itself and by a deep branch of the ulnar artery. for patients with a brachial artery–based fistula (a) is RUDI (b), Venous grafts are preferred to prosthetic grafts for hand by- which involves ligating the fistula at its origin, lengthening the passes. All venous grafts are tunneled anatomically. In a radial original venous graft with an additional vein segment, and artery reconstruction, the graft is tunneled over the anatomic reestablishing the fistula by anastomosing the lengthened graft to the radial artery (as shown) or the ulnar artery. snuff box onto the dorsum of the hand, between the thumb and the index finger, to join the deep palmar arch. In an ulnar artery reconstruction, the venous graft takes a less circuitous course, venous graft becomes occluded, the fistula is ligated.This step fre- passing superficial to the flexor retinaculum at the wrist to join quently leads to resolution of the symptoms of arm ischemia. the superficial palmar arch. HAND REVASCULARIZATION Operative Technique Patients with rest pain in the hands and digital ulcers often have The donor limb that will provide the venous graft is prepared. significant comorbid conditions (e.g., collagen vascular or The brachial artery is exposed as described previously [see Pro- rheumatologic disorders, end-stage renal disease, or hypercoagu- cedures for Acute Arm Ischemia, Brachial Embolectomy, Oper- lable states). In addition, patients who have received organ trans- ative Technique, above]. plants and are taking immunosuppressive medications may expe- The course of the radial artery in the forearm follows an oblique rience severe occlusion of forearm or palmar arteries. Younger line from the brachial artery pulse medial to the biceps tendon to patients with hand ischemia are often manual laborers who have the styloid process of the radius. In the midforearm, the radial hypothenar hammer syndrome. Patients with established signs artery is medial to the brachioradialis and lateral to the flexor carpi and symptoms of hand ischemia have little to lose by undergoing radialis. A lateral longitudinal incision is made, and the muscles revascularization: there are few viable therapeutic alternatives. are separated to reveal the radial artery. At the wrist, the radial Aggressive treatment of hand ischemia is worthwhile, in that it artery is exposed by making a longitudinal incision between the achieves rapid relief of symptoms and offers the opportunity for tendon of the flexor carpi radialis and the tendon of the brachio- hand and limb salvage. The techniques resemble those employed radialis.This is the site of the radial artery pulse in normal persons. for distal bypass in the leg [see 6:17 Infrainguinal Arterial Proce- Here, the artery is superficial, and exposure is relatively straight- dures]. Early results from several centers indicate that hand bypass forward. Care must, however, be taken not to injure the superficial procedures can be performed with low morbidity and good long- branch of the radial nerve, which is often located near the lateral term patency.29,30 Postoperative life expectancy, however, is often aspect of the artery. Injury to this nerve branch can result in trou- limited by the comorbid conditions present. blesome paresthesia along the lateral aspect of the thumb. The course of the ulnar artery runs from the medial epicondyle Preoperative Evaluation of the humerus to the pisiform bone. In the midforearm, the ulnar Preoperative evaluation for hand bypass should follow the same artery lies beneath the deep fascia between the belly of the flexor protocol as that for any elective revascularization: preoperative digitorum laterally and the belly of the flexor carpi ulnaris medial- angiography to delineate anatomy with vein mapping to identify a ly.The ulnar nerve joins the artery on its lateral aspect for the dis- venous conduit. tal two thirds of the vessel’s length; this nerve may be injured if not Many patients with hand ischemia have intractable pain from carefully identified and preserved. At the wrist, the ulnar artery is ulcerative lesions, gangrene, or both. Their main requirement is lateral to the tendon of the flexor carpi ulnaris. It is exposed by adequate relief of pain; improved hand function is a secondary locating this tendon (which is the most medial tendon palpable at
  9. 9. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 9 a First Dorsal Interosseous Muscle Radial Artery b Figure 8 Hand revascularization. (a) Shown is exposure of the distal radial artery. (b) The deep palmar arch is exposed via an incision made across the medial border of the thenar eminence. the wrist) and making a vertical skin incision lateral to it. Although the hand and division of the oblique head of the adductor pollicis the ulnar artery lies deeper than the radial artery at the wrist, it is are then required to provide access to the origin of the deep pal- just as easily exposed. Superficial to the ulnar artery, palmar cuta- mar arch. neous branches of the ulnar nerve may be identified; these should also be preserved. Exposure of ulnar artery and superficial palmar arch Grafts originating from the brachial artery are tunneled in the Like exposure of the radial artery, exposure of the ulnar artery and subcutaneous plane. Subcutaneous tunneling facilitates physical the superficial palmar arch is fairly straightforward. In reality, these examination to determine the patency of the bypass, as well as sur- vessels are no smaller than the tibial and pedal vessels in the leg. A veillance of the bypass with duplex ultrasonography. Alternatively, curved incision is made along the lateral border of the hypothenar if good-quality basilic or cephalic veins are present, an in situ eminence [see Figure 9a].The aponeurotic layer is divided, and the bypass may be performed. artery is exposed in the upper part of the palm at the origin of the superficial palmar arch. There are no major nerves in the vicinity, Exposure of radial artery and deep palmar arch Ex- and it usually is not difficult to expose a reasonable length of artery posure of the radial artery is relatively straightforward. Generally, for an arterial anastomosis [see Figure 9b]. Alternatively, the super- it may be accomplished as previously described (see above). ficial palmar arch may be exposed in the palm by making an inci- Alternatively, it may be accomplished by making a vertical incision sion along one of the larger vertical or oblique skin creases. over the anatomic snuff box (which lies between the extensor pol- Postoperative Care licis longus tendon posteriorly and the tendons of the extensor pollicis brevis and the abductor pollicis longus anteriorly). This As with all venous grafts, postoperative graft surveillance is incision is then deepened through the subcutaneous tissues to essential. Routine postoperative anticoagulation generally is not expose the radial artery in the floor of the snuff box [see Figure 8a]. warranted. This area contains no significant nerves and thus is often chosen as a site for hemodialysis access. The deep palmar arch is much less accessible than the radial Alternative Therapies for Chronic Arm Ischemia artery. Consequently, exposure of this vascular structure is consid- THORACOSCOPIC SYMPATHECTOMY AND DIGITAL erably more difficult than exposure of the radial artery. The deep SYMPATHECTOMY palmar arch extends across the palm, level with the proximal bor- der of the outstretched thumb. To expose it, an incision is made Our experience with sympathectomy in the treatment of along the medial border of the thenar eminence [see Figure 8b]. patients with critical hand ischemia or digital ulceration has been, Extensive dissection of the superficial and deep flexor tendons of frankly, disappointing. When we do perform sympathectomy, we
  10. 10. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 10 a b Digital Arteries Ulnar Figure 9 Hand revasculariza- Nerve tion. (a) The distal ulnar artery and the superficial palmar arch are exposed via a curving incision Ulnar Superficial made along the lateral border of Artery Palmar Arch the hypothenar eminence. (b) Shown is exposure of the distal ulnar artery and the superficial Median palmar arch, along with the ulnar Nerve and median nerves. prefer the thoracoscopic approach to the traditional cervical route. Phenomenon],35 the results in patients with peripheral ischemia are Either way, however, the results have been discouraging; any less encouraging. At present, iloprost is mainly used to treat improvements noted prove to be only temporary. Sympathectomy patients with digital ulcers caused by systemic sclerosis, systemic may help alleviate pain in these patients, but even in this regard, lupus erythematosus, mixed connective tissue disease, or cuta- the results are, at best, unpredictable. A review of the literature neous polyarteritis nodosa. There are no good data on its use to seems to support this conclusion. Admittedly, the available data on treat patients with digital ulcers caused by diabetes mellitus, ath- thoracoscopic sympathectomy for digital ischemia are sparse: to erosclerosis, or renal impairment; however, a study of iloprost date, only three reports encompassing 21 patients have been pub- therapy for arterial leg ulcers found that the success rate was lower lished.31-33 In contrast, there is a wealth of data on thoracoscopic than 50%.36 sympathectomy for hyperhidrosis. GUANETHIDINE BLOCKS An alternative technique has been devised in which a very dis- tal sympathectomy is performed at the level of the origin of the Transvenous regional guanethidine blocks have also been proper digital arteries. The sympathectomy site is exposed via a employed to treat critical digital ischemia. Patients receive a sin- palmar approach, and a 3 to 4 mm length of the adventitia is gle block, with 5 mg of guanethidine in 60 ml of normal saline removed from the proper digital arteries distal to the junction of injected into a superficial vein of the affected hand under 30 the distal perforating artery with the common digital artery. This minutes of arterial arrest. In successful cases, hyperemia is procedure appears to be well tolerated, and data from small series induced in the treated upper limb, and blood flow to the fingers attest to its value in selected patients with digital ulcers.34 improves. The effects of these blocks are said to persist for up to 1 month. Patients who have finger ulcers, however, appear to be PROSTACYCLINS less responsive than those whose only symptom is pain. The The prostacyclin analogue iloprost has been used in Europe to advantages of this treatment approach are that it is free of side treat patients with hand ischemia. Although iloprost therapy effects and that it can be repeated for as long as necessary37; the appears to be reasonably effective in patients with vasospastic dis- disadvantage is that it must be repeated at monthly intervals for orders, such as Raynaud syndrome [see 6:24 Raynaud as long as necessary.
  11. 11. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 15 UPPER-EXTREMITY REVASCULARIZATION PROCEDURES — 11 References 1. Hernandez-Richter T, Angele MK, Helmberger T, subclavian arterial occlusive lesions. Vasc Endovas- current management. Curr Surg 63:130, 2006 et al: Acute ischemia of the upper extremity: long- cular Surg 40:27, 2006 27. Minion DJ, Moore E, Endean E: Revision using dis- term results following thromboembolectomy with 16. Brountzos EN, Petersen B, Binkert C, et al: Primary tal inflow: a novel approach to dialysis-associated the Fogarty catheter. Langenbecks Arch Surg stenting of subclavian and innominate artery occlu- steal syndrome. Ann Vasc Surg 19:625, 2005 386:261, 2001 sive disease: a single center’s experience. Cardiovasc 28. Ehsan O, Bhattacharya D, Darwish A, et al: 2. 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