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Vascular
disorders encompass a broad spectrum of pathology that results in aberrant
microvascular perfusion, potentially threatening the viability of the hand or
digits.
There are numerous causes of vascular disorders of the upper extremity
and hand, and to understand them it is valuable to classify vascular
disorders into acute or chronic categories.
Acute
Vascular Disorders
Acute
injury due to trauma is covered extensively in the replantation section of this
site and in the free flap section where examples of severe vascular injury are
presented. A
subcategory of acute injury is
iatrogenic disease due to radial artery
catheterization or drug injection. Both are treated with the same
principles as major vascular injury. Compartment Syndrome is a condition of increased pressure in the hand or
forearm that causes acute loss of blood flow and nerve injury. Treatment
is directed toward treating the increase pressure which causes loss of blood
flow, and often requires fasciotomy.
Chronic
Vascular Disease
Chronic
vascular disorders tend to develop more slowly and have a tendency, but not
always, to be seen in an older population.
Arteriosclerosis
of the brachial, radial or ulnar artery may require surgical exploration and
possibly saphenous vein interposition grafting.
Although angioplasty is often used to treat arteriosclerotic lesions, radial
and ulnar artery arteriosclerosis is best treated by surgery.
Frequently, both radial and ulnar arteries are affected by disease
and hence the patient presents with symptoms.
A complete arch with good distal flow may require only single vessel
repair.
Arteriosclerotic changes
in the hand and finger arteries are difficult to treat and often associated with
severe systemic disease and diabetes. Distal
vessels must be present on angiography in order for vein grafts to have distal
vessels to plug into. Amputation
may be the only option in some cases.
Aneurysms and thromboses
can be resected and repaired with interpositional vein grafts.
The most common upper extremity thrombosis involves the hypothenar hammer
syndrome, or ulnar hammer syndrom. A
thrombosis and/or aneurysm of the ulnar artery at the hook of the hamate
presents as a result of repetitive trauma in a laborer.
Symptoms include hand ischemia and swelling and pain in the palm.
Embolism in the larger finger,
hand and forearm vessels can be embolectomized with a balloon catheter or
sometimes under direct vision via an arteriotomy.
Very distal embolism may require infusion of streptokinase or tissue
plasminogen activator to dissolve clot and allow reperfusion.
Large vessel acute embolism and reperfusion may result in edema and
compartment syndrome requiring fasciotomy.
A high index of suspicion must be maintained.
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