Endovascular Therapy for Below-the-Elbow Arterial Disease: An Initial Single-Center Experience

Abstract

Purpose: To evaluate the technical success, clinical success, and complication rates of endovascular revascularization for below-the-elbow (BTE) peripheral artery disease. Materials and Methods: A retrospective review was performed of 19 patients (mean age 63 years; 12 men) with critical hand ischemia (CHI) who underwent 25 interventions in 19 arms between October 2010 and June 2017. Access was attained using 4-F or 5-F sheaths via antegrade brachial, retrograde radial, or fistula/graft access routes depending on the target vessel. A 0.018-inch hydrophilic microwire was used for intimal or subintimal recanalization. Angioplasty was performed over a 0.014-inch guidewire using low-profile balloons. The primary endpoint of the study was technical success, defined as successful lesion crossing/dilation, with residual stenosis <30%. Clinical success referred to improvement in pain and/or steal symptoms. Results: Technical success was achieved in 88% (22 of 25 procedures), with no significant difference in outcome associated with indications or baseline vessel disease. Complications occurred in 6 cases, of which 5 were minor and 1 was major. Clinical success was achieved in 12 of 14 patients with available follow-up; 5 of 7 patients with ulcers experienced wound healing. Conclusion: Endovascular revascularization for BTE occlusive disease is an effective and safe strategy for treating CHI.

Percutaneous Transluminal Angioplasty for Below-the-Elbow Critical Hand Ischemia: A Systematic Review

“…Following full-text review, 8 articles remained that met the previously specified eligibility criteria. 3 , 4 , 6 - 10 , 13 …”

“…Revascularization was achieved or initially attempted predominately using an antegrade brachial puncture and 4- or 5-Fr vascular sheath. 3 , 4 , 7 - 10 Other alternatives used in failed antegrade brachial cases included dual access (for example, femoral and radial artery, or radial artery/palmar arch), 9 fistula/graft access, 8 retrograde transradial access, 10 or the palmar-loop-technique. 2 , 16 Two studies exclusively used the femoral artery for access.…”

“… 4 , 5 There is usually a diffuse involvement of the BTE vessels, including the ulnar artery, radial artery, palmar arch, and digital vessels, with seldom isolated involvement of the interosseous artery. 4 - 10 Distal calcific arteriosclerosis plays a pivotal role in the pathophysiology of hand ischemia, particularly in hemodialysis patients. 5…”

“… 12 , 13 In the last 2 decades, several studies have shown promising results with percutaneous transluminal angioplasty (PTA) of BTE arteries for the management of CHI. 3 , 4 , 6 - 10 , 13 This systematic review aims to assess the feasibility, technical success, long-term outcomes, and complications of PTA for the treatment of CHI due to BTE arterial disease.…”

Successful Endovascular Therapy for Total Occlusion of the Distal Radial and Ulnar Artery with Palmar Artery Lesion in a Patient with Critical Hand Ischemia Associated with Systemic Sclerosis

“…This report describes a rare case of technically and clinically successful revascularization in a BTE lesion with total occlusion from the distal RA and UA to the palmar artery in a patient with SSc. Endovascular therapy for BTE lesions in patients with CHI associated with atherosclerosis has been reported as a feasible treatment option for revascularization 5-8 ; therefore, endovascular intervention for BTE lesions in patients with CHI associated with SSc might be considered as a treatment option. An antegrade approach should be attempted first in BTE interventions, but a retrograde approach via the palmar arch may be useful as an alternative if this attempt fails.…”