Abstract
Background/Purpose
Critical hand ischemia (CHI) can be devastating and may result in amputation. Distal vessel calcification has been shown to be a major factor in causing CHI. Atherectomy in the upper extremities is not typically considered due to the small anatomy; however, the Diamondback 360° Peripheral Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc.) can access treatment areas with a reference vessel diameter of 1.5 mm.
Methods/Materials
A retrospective, observational, single center (Merit Health Center, Jackson, MS) analysis of 11 CHI patients with calcific disease of the radial artery treated with orbital atherectomy (OAS) was completed. Demographics and procedural to 30-day outcomes were assessed.
Results
All patients had good blood flow to the hand after intervention and none experienced complications during or immediately post-procedure. At 30-days the freedom from revascularization and amputation was 100%, and all the wounds were healed. The following important principles were followed during the use of OAS for CHI: (1) ACT was therapeutic (~250 s); (2) Gentle wire manipulation; (3) Utilization of a small OAS crown (1.25 mm); (4) Aggressive vasodilator use—given through the exchange catheter; (5) Angioplasty balloon was matched to the size of the vessel and long and low pressure inflations were completed.
Conclusions
Critical hand ischemia can be treated with endovascular techniques. Obtaining good outflow to the fingers is critical for wound healing and preventing amputation. Orbital atherectomy is a useful tool in preparing vessels for balloon angioplasty; particularly in cases where calcification is present.
Highlights
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In this report, we describe the outcomes of eleven (11) successful cases of radial artery revascularization, with a detailed description of one representative case.
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To our knowledge, this is the first below-the-elbow atherectomy study of 11 patients with CHI due to calcified radial artery treated with orbital atherectomy.
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All patients had good flow to the hand after intervention and none experienced complications during or immediately post-procedure.
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The following important principles were followed during the use of OAS for CHI: (1) ACT was therapeutic (~250 s); (2) Gentle wire manipulation; (3) Utilization of a small OAS crown (1.25 mm); (4) Aggressive vasodilator use—given through the exchange catheter; (5) Angioplasty balloon was matched to the size of the vessel and long and low pressure inflations were completed.
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Orbital atherectomy is a useful tool in preparing vessels for balloon angioplasty; particularly in cases where calcification is present.
1
Introduction
Critical hand ischemia (CHI) is less common than critical limb ischemia, however it can be devastating and may result in amputation . Patients with CHI usually present with pain, discoloration, necrotic tissue, and/or gangrene of fingers . It can be caused by obstruction of the above- or below-the-elbow arteries. Below-the-elbow (BTE) artery disease is more prevalent in diabetic patients or in patients with end-stage renal disease (ESRD) on hemodialysis . Both diabetes and ESRD, as well as older age, are the main risk factors for peripheral artery calcification and it has been shown that distal vessel calcification is a major factor in causing CHI . It is well known that calcified lesions are technically challenging, they respond poorly to angioplasty, they are difficult to completely dilate, and prone to dissection during balloon angioplasty . Lesion preparation before balloon angioplasty with atherectomy is essential in complex calcified lesions , however, atherectomy in BTE arteries is not typically considered due to the small anatomy. The Diamondback 360° Peripheral Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc.) is one of the atherectomy devices that can access treatment areas with a reference vessel diameter of 1.5 mm. In this report, we describe the outcomes of eleven (11) successful cases of radial artery revascularization via orbital atherectomy, with a detailed description of one case.
2
Material and methods
A retrospective, observational, single center (Merit Health Center, Jackson, MS) analysis of 11 critical hand ischemia (CHI) patients with calcific disease of the radial artery treated with orbital atherectomy (OAS) was completed. Demographics and procedural to 30-day outcomes were assessed.
2
Material and methods
A retrospective, observational, single center (Merit Health Center, Jackson, MS) analysis of 11 critical hand ischemia (CHI) patients with calcific disease of the radial artery treated with orbital atherectomy (OAS) was completed. Demographics and procedural to 30-day outcomes were assessed.
3
Results
The average age was 53 years and the majority of the patients were African-American and male. Eighty-two percent of the patients suffered from end-stage renal disease (ESRD) and 91% of them had a finger wound. Table 1 summarizes the demographic characteristics of the patients in this study. The radial artery was treated in all patients with orbital atherectomy using a 1.25 mm crown (micro or solid). The average balloon inflation pressure was 5.7 atm, and the angiographic success was 100%. The following important principles were followed during the use of OAS for CHI: (1) ACT was therapeutic (~250 s); (2) Gentle wire manipulation; (3) Utilization of a small OAS crown (1.25 mm); (4) Aggressive vasodilator use—given through the exchange catheter; (5) Angioplasty balloon was matched to the size of the vessel and long and low pressure inflations were completed.
| Average age | 53 years (n = 11) |
| Male | 91% (10/11) |
| African-American | 73% (8/11) |
| Diabetes | 82% (9/11) |
| Hypertension | 100% (11/11) |
| Peripheral vascular disease | 100% (11/11) |
| End-stage renal disease | 82% (9/11) |
| Finger wound or necrotic tissue | 91% (10/11) |
| Duration of symptoms (onset to intervention) | 6–12 weeks |
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