Hypothenar hammer syndrome: Distal ulnar artery reconstruction with autologous inferior epigastric artery

Transcription

1 From the Eastern Vascular Society Hypothenar hammer syndrome: Distal ulnar artery reconstruction with autologous inferior epigastric artery Hadley E. Smith, MD, a Marco Dirks, MD, b and Robert B. Patterson, MD, a Providence, RI Digital artery embolization and ulnar artery thrombosis are consequences of repetitive trauma and can lead to digit loss and debility from ischemia and cold intolerance. We postulate that an arterial autograft is a theoretically superior conduit to traditional saphenous vein, and report reconstruction with inferior epigastric artery. Three adult male smokers, ages 39 to 49 years, had severe digital ischemia and cold-induced vasospasm. Arteriograms confirmed occlusion of the distal ulnar artery without direct perfusion of the superficial palmar arch, distal digital artery embolization, and normal proximal vasculature. All reconstructions were performed from the distal most patent ulnar artery at the wrist to the superficial palmar arch (1 patient) or sequentially to the involved common digital arteries (2 patients), with inferior epigastric artery. Handling characteristics and size match between the arterial autografts and bypassed arteries was excellent. Patency has been confirmed with duplex scanning at follow-up of 8 to 24 months, with resolution of cold intolerance and successful digital preservation. (J Vasc Surg 2004;40: ) Hypothenar hammer syndrome is a rare cause of digital ischemia, first described by Van Rosen in and named by Conn et al 2 in It is the consequence of repetitive palmar trauma leading to injury of the ulnar artery passing adjacent to the hook of the hamate. The ulnar artery can become aneurysmal, thrombose, or send emboli to the digital arteries. Patients typically complain of digital cold intolerance, cyanosis, and ischemic pain. Frequently these are patients with an occupational history in machinery, carpentry, or any industry requiring repeated striking of tools. In addition, case reports have described this syndrome in mountain bikers, hockey players, and karate experts. 3-6 The goals of treatment are to restore blood flow to the ischemic digits and to prevent further thrombotic or embolic episodes. Studies have shown symptomatic improvements with excision of the abnormal ulnar artery segment and distal bypass to the involved palmar arch branches, with patency rates from 84% to 100% at variable follow-up intervals. 7-9 Symptomatic improvements were influenced by other factors, including duration of preoperative symptoms, acute versus chronic occlusion, and smoking history. 7 The coronary artery bypass experience has shown that arterial conduits have superior long-term patency. In theory, an arterial conduit would be beneficial in this relatively From the Department of Surgery, Division of Vascular Surgery, a and the Department of Orthopedic Surgery, b The Miriam Hospital and Brown University School of Medicine. Competition of interest: none. Presented at the Eighteenth Annual Meeting of the Eastern Vascular Society, Philadelphia, Pa, Apr 29-May 2, Reprint requests: Robert B. Patterson, MD, Brown University Medical School, Providence Surgical Care Group, 486 Silver Spring St, Providence, RI ( Robert_patterson@brown.edu) /$30.00 Copyright 2004 by The Society for Vascular Surgery. doi: /j.jvs young and active patient population. We have begun using the inferior epigastric artery for ulnar artery bypass, because of its ease of harvest and comparable size match to the distal ulnar artery. PATIENTS From December 1, 2001 until July 15, 2003, 3 adult men with debilitating digital ischemia and the clinical presentation of hypothenar hammer syndrome received treatment. All 3 patients were smokers, with occupational history of repetitive trauma to the affected hand. Each had critical ischemia and debilitating symptoms. Initial evaluation included detailed history and physical examination, laboratory testing for autoimmune disease and thrombophilia, and a combination of digital photoplethysmography (PPG), duplex scanning, and arteriography. In addition, duplex scanning of the inferior epigastric arteries was performed to determine caliber and patency for use as a conduit, with qualitative assessment of the conduit based on experience with pre-bypass assessment of both vein grafts and radial arteries. CASE REPORTS Case 1. Patient 1 is a 39-year-old male construction worker with a 2 pack per day smoking habit, with a 6-month history of numbness in the left middle and ring fingers, and progressive increase in pain and cyanosis. He initially received treatment for carpal tunnel syndrome, a splint was placed, and he was temporarily taken out of work. The symptoms improved with splinting and rest, but worsened on return to work. Physical examination at presentation was significant for bluish discoloration and pallor of the middle and ring fingers over the distal phalanges, mild tenderness at palpation, and pain with active flexion. The left radial pulse was palpable, but the left ulnar pulse was not. Digital PPG tracings showed flattened waveforms in the middle and ring fingers. Arteriograms demonstrated occlusion of the

2 JOURNAL OF VASCULAR SURGERY Volume 40, Number 6 Smith et al 1239 Fig 2. Left ulnar to common digital arteries 3 and 4 bypass graft with use of a branched inferior epigastric artery. Fig 1. (Case 1) Digital subtraction arteriogram. superficial palmar arch and poor filling of the vessels of the third and fourth fingers (Fig 1). The patient was admitted to the hospital,l and intravenous heparin was initiated, along with continuous diltiazem infusion. Operative intervention was planned to bypass the affected arteries. The patient underwent bypass from the left ulnar to common digital arteries 3 and 4, with use of a branched inferior epigastric artery (Fig 2). Case 2. Patient 2 is a 42-year-old male carpenter with a 22 pack-year history of smoking who complained of several weeks of pain and coolness of the index, middle, and ring fingers of the right hand, which were exacerbated by cold. He had no history of symptoms of Raynaud syndrome. Physical examination demonstrated palpable proximal radial and ulnar pulses on the right, with loss of the ulnar pulse distal to the wrist crease. The right index, middle, and ring fingers were cool, cyanotic, and tender to touch. PPG tracings were flat in the symptomatic digits and normal in the remaining digits. Duplex scans showed thrombosis of the distal ulnar artery, without evidence of aneurysm. Arteriograms confirmed occlusion of the distal artery, with reconstruction of a diminutive superficial arch fed by a stenotic branch of the radial artery. There was a generous deep palmar arch; however, this did not directly feed the affected digital arteries, and there was no direct communication between the radial and ulnar arteries nor adequate collateral vessels. Initial conservative therapy with smoking cessation and initiation of calcium channel blockers was unsuccessful. The patient was admitted for revascularization of the ulnar artery, and underwent an ulnar artery to superficial plamar arch bypass, with use of the inferior epigastric artery. Case 3. Patient 3 is a 49-year-old male construction worker with a 50 pack-year smoking history and a remote history of mild symptoms of Raynaud syndrome. He had a 3-week history of pain and fullness of the ring finger on the right, nondominant hand, which had become progressively more severe. Physical examination was significant for absent distal ulnar pulse on the right, with a palpable radial pulse. An Allen test on the right yielded abnormal findings, showing pallor with occlusion of the radial artery and no change with occlusion of the ulnar artery. The ring finger was cool, with a woody turgor, poor sensation, and no 2-point discrimination. The fifth finger had superficial desquamation distally. PPG tracings showed bilateral digital vasospasm and inflow impairment of the right fourth and fifth fingers. Duplex scans showed occlusion of the right ulnar artery at the level of the proximal wrist crease. Arteriograms revealed occlusion of the ulnar artery, with reconstitution of portions of the distal superficial palmar arch from small collateral vessels from the deep arch. The patient underwent sequential bypass grafting from the ulnar artery to the proper third and fourth web space digital arteries, with use of the inferior epigastric artery. TECHNIQUE All procedures were performed with the patient under general anesthesia, 1 with an additional axillary block initiated preoperatively because of severe digital ischemia. A diltiazem infusion at 15 mg/hr was used during the entire procedure, and continued into the postoperative period. The hand was approached through a curvilinear incision from the distal forearm crease overlying the ulnar artery, across the hypothenar eminence, and transversely along the course of the superficial palmar arch. The right inferior epigastric artery was harvested through a paramecia incision. The anterior rectus sheath was opened, and the rectus muscle was bluntly dissected to expose the retro-rectus space. The epigastric artery was easily identified at this point, near its origin from the proximal common femoral artery beneath the inguinal ligament. The perivascular sheath was injected with papaverine solution to minimize spasm. The artery was then dissected distally with a pedicle of veins from the surrounding tissue with a harmonic scalpel to minimize trauma to the conduit. Muscular perforating branches of appropriate size were dissected free as well, for branch reconstruction (Case 1, Fig 2). Before

3 1240 Smith et al JOURNAL OF VASCULAR SURGERY December 2004 Fig 3. Left ulnar bypass, proximal and distal anastomoses at 1-year follow-up. harvesting of the artery, patients received anticoagulation with a 5000-unit intravenous bolus of heparin. All reconstructions were performed with loupe magnification, from the distal most patent ulnar artery at the wrist to the superficial palmar arch (patient 2) or to the involved common digital arteries (patients 1 and 3) The wounds were closed, the hand was splinted, and the patients were transferred to the recovery room with continuous infusion of diltiazem at 15 mg/hr and continuous infusion of low molecular weight dextran for 24 hours. The patients were discharged on the first postoperative day, with diltiazem 240 mg/d. No antiplatelet agents were continued. RESULTS Postoperatively all 3 patients had resolution of symptoms. Follow-up duplex scans and PPGs were performed at 6 and 8 weeks, every 3 months for 1 year, then annually thereafter. Complete follow-up ranged from 7 to 24 months. All grafts have remained patent, with no evidence of intimal hyperplasia within the conduit at the proximal or distal anastomoses (Fig 3). Previously flat digital PPGs have become normal (Fig 4), with patient 3 exhibiting the notched Raynaud pattern digital tracing, consistent with the history of Raynaud-type symptoms. 10 All patients continue to take diltiazem indefinitely. Although all 3 patients were able to stop tobacco abuse perioperatively, despite extensive counseling all have resumed previous smoking habits. Two patients have returned to their previous work, but with instructions to avoid repetitive trauma, and 1 patient is seeking alternative employment. DISCUSSION Several case reports describe hypothenar hammer syndrome, but there are few large series of patients. Excision of the diseased segment of artery and revascularization is considered the treatment of choice in these patients. There are a few studies with long-term follow-up of patients who have undergone saphenous vein graft ulnar artery bypass to treat symptoms and graft patency. The largest series published to date included 19 patients followed up on average for 22 months (range, 1-66 months) by Ferris et al. 9 Overall patency was 84%, with late graft occlusion occurring at 14, 15, and 35 months. In a smaller study, Harris et al 8 treated 6 patients over 7 years with saphenous vein interposition grafts, because of symptomatic ulnar artery aneurysm. Follow-up was 13 to 57 months (mean, 24 months), with 100% patency at duplex scanning. In general these patients are young and active, which makes long-term patency especially important. Although these patients may not be at risk for recurrent occlusion from an atherosclerotic mechanism, they are still at risk for the repeated trauma that incited the problem originally. In addition, hypercellular, proliferative vein graft hyperplasia is theoretically prone to occur in response to arterial hemodynamics. For coronary artery bypass grafting (CABG), arterial autografts (eg, internal thoracic artery, radial artery) are superior to saphenous vein grafts. Higher late patency rates for arterial grafts have been attributed to both the anatomy and physiologic activity of the donor artery. Arterial conduits retain their responsiveness to endogenous agonist, and their ability to secrete endothelial-derived endogenous vasodilators. 11 The inferior epigastric artery has been used in CABG for many years in an effort to improve long-term patency. In one series by Buche et al, 12 patency rates evaluated at angiography were 97% in the early postoperative period and 86% on average at 25 months of follow-up. Puig and colleagues 13 showed similar results at follow-up of 11 to 92

4 JOURNAL OF VASCULAR SURGERY Volume 40, Number 6 Smith et al 1241 Fig 4. Preoperative and postoperative digital photoplethysmograms. Flat wave forms of symptomatic middle and ring digits of left hand, normalized to pulsatile wave form after bypass. months (average, 81 months), demonstrating potential for long-term durability. More data are available that evaluate the internal thoracic artery for durability for CABG. Comparative histologic studies have been done to compare the internal thoracic artery with alternative arterial conduits, including the inferior epigastric artery. The inferior epigastric artery is more muscular than the internal thoracic artery, with fewer elastic lamellae, but it has characteristics that make it a good candidate for a free graft. In comparison with other muscular arteries, such as the radial or gastroepiploic arteries, the inferior epigastric artery has a thinner media, in theory making the free graft less susceptible to ischemia, with better nourishment from the lumen. 14 In addition, in an ex vivo study by Mugge et al 15 the inferior epigastric artery demonstrated favorable physiologic responses to vasodilators and constrictors. The inferior epigastric artery showed a weak constriction response to histamine at a level significantly less than the internal thoracic artery. The internal thoracic artery and inferior epigastric artery had similar vasodilatory reactions to nitroglycerin; however, the inferior epigastric artery responded with increased endothelium-dependent relaxation in response to acetylcholine, substance P, and bradykinin. This indicates that the inferior epigastric artery free graft is still able to secrete and respond to endothelium-derived relaxation factor. It remains unclear whether endothelium-derived relaxation factor has an effect on long-term patency, but the ability to respond to vasodilatory stimuli provides a theoretical advantage as a conduit. In addition to these theoretic benefits, there are real technical advantages to use of autologous epigastric artery. The size match between the inflow ulnar artery and the proximal epigastric artery proved to be excellent in all cases, and was predicted on preoperative duplex scans. The epigastric artery tapers as it gives off muscular branches, and the distal size match to the common digital arteries is also satisfactory. Using a muscular branch for the branched reconstruction eliminated a sequential end-to-side anastomosis, and again resulted in excellent size match. Handling characteristics of the arterial conduit were superior to small veins of appropriate size for the bypass. CONCLUSIONS Given the problems with saphenous vein graft stenosis in other applications, an arterial conduit, in theory, may provide better long-term patency for ulnar artery bypass.

5 1242 Smith et al JOURNAL OF VASCULAR SURGERY December 2004 The morphologic and histologic properties of the inferior epigastric artery and its success as a CABG suggest good durability. Even if patency of vein grafts is acceptable, digital artery reconstruction with autologous inferior epigastric artery has practical advantages over saphenous vein, with excellent size match and handling characteristics. The theoretic advantages inherent in arterial autografts are particularly appealing in patients who will likely continue tobacco abuse and high-risk employment. Our experience to date with intermediate follow-up supports the use of the inferior epigastric artery in treatment of hypothenar hammer syndrome. REFERENCES 1. Von Rosen S. Ein Fall von Thrombose in der Arteria ulnaris nach Einwirkung von stumpfer Gewalt. Acta Chir Scand 1934;73: Conn J, Bergan J, Bell J. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery 1970;68: Kreitner KF, Duber C, Muller LP, Degreif J. Hypothenar hammer syndrome caused by recreational sports activities and muscle anomaly in the wrist. Cardiovasc Interv Radiol 1996;19: Applegate K, Spiegel P. Ulnar arery occlusion in mountain bikers. J Sports Med Phys Fitness 1995;35: De Monaco D, Fritsche E, Rigoni G, Schlunke S, Von Wartburg U. Hypothenar hammer syndrome: retrospective study of nine cases. J Hand Surg 1999;24B: Vayssairat M, Debure C, Cormier J, Bruneval P, Laurian C, Juillet Y. Hypothenar hammer syndrome: seventeen cases with long-term followup. J Vasc Surg 1987;5: Mehlhoff T, Wood M. Ulnar artery thrombosis and the role of interposition vein grafting: patency with microsurgical technique. J Hand Surg 1991;16A: Harris E, Taylor L Jr, Edwards J, Mills J, Porter J. Surgical tratment of distal ulnar artery aneurysm. Am J Surg 1990;159: Ferris B, Taylor L Jr, Oyama K, McLafferty R, Edwards J, Moneta G, et al. Hypothenar hammer syndrome: proposed etiology. J Vasc Surg 2000;31: Sumner D, Strandness DE, Jr. An abnormal finger pulse associated with cold sensitivity. Ann Surg 1972;175: Luscher T, Diederich D, Siebenmann R, Lehmann K, Stulz P, von Segesser L, et al. Differences between endothelium-dependent relaxation in arterial and in venous coronary bypass grafts. N Engl J Med 1988;319: Buche M, Schroeder E, Gurne O, Chenu P, Paquay J, Marchandise B, et al. Coronary artery bypass grafting with the inferior epigastric artery. J Thorac Cardiovasc Surg 1995;109: Puig L, Sousa A, Cividanes G, Souto R, Bittencourt A, Oppi E, et al. Eight years experience using the inferior epigastric artery for myocardial revascularization. Eur J Cardiothorac Surg 1997;11: van Son J, Smedts F, Vincent J, van Lier H, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99: Mugge A, Barton M, Cremer J, Frombach R, Lichtlen P. Different vascular reactivity of human internal mammary and inferior epigastric arteries in vitro. Ann Thorac Surg 1993;56: Submitted May 15, 2004; accepted Sep 14, 2004.