S C I E N C E
O F
M E D I C I N E
Treatment of Critical Hand Ischemia with Atherectomy and Balloon Angioplasty in a Hemodialysis Patient Abdul Bahro, MD, FACC, FSCAI; Connie Williams, AGACNP-BC; and William C. Lineaweaver, MD, FACS
Abstract A patient with critical arteriosclerotic ischemia of his left upper extremity was treated with angiographic atherectomy and balloon angioplasty, resulting in restoration of circulation to his hand, resolution of pain, restoration of function, and healing of ischemic finger necrosis. Keywords: upper extremity ischemia; angiography; angioplasty Introduction A common problem plaguing diabetic and end-stage renal disease patients is the development of calcified peripheral artery disease of the forearm and hand. Severe pain and critical hand ischemia can develop, leading to amputations. Unfortunately, only sparse data are available for therapeutic treatments of calcified lesions distal to the elbow.1-4 Studies have proven that heavily calcified lesions are effectively treated with atherectomy followed by balloon angioplasty below the knee, but below the elbow lesions are often excluded from therapeutic consideration because of small vessel size.5-6 We present a case of upper extremity critical ischemia treated with atherectomy and angioplasty, illustrating the utility of this strategy in the forearm and hand. Case Report The patient was a 69-year-old man with a past medical history of hypertension, diabetes mellitus, hyperlipidemia, and end-stage renal disease on hemodialysis. He was referred from his dialysis center for resting ischemia to the left hand. He had an arteriovenous fistula for dialysis in his proximal left arm. He developed severe pain, discoloration, and necrotic areas to the tips of his fingers. He was previously admitted to another local hospital for 12 days and treated with anticoagulation with no improvement in his ischemic symptoms. His pain progressively worsened, and necrotic areas were increasing in size. The pain was so severe he was unable to move his fingers (Figure 1). He was then referred to our facility. An arterial Doppler study review of the left upper extremity showed severe peripheral arterial disease, and the patient was scheduled for angiography. The images revealed severe disease in the proximal and
158 vol. 61 • no. 6/7 • 2020
mid-left radial artery with an occluded segment just proximal to the wrist, along with an occluded ulnar artery distal to the wrist (Figure 2). The recommendation was to proceed with endovascular intervention to the radial artery. Figure 1. Resting Ischemic Changes to the Left Hand
