Our medical treatment protocol for symptomatic distal ulnar artery occlusion

Arterial occlusive disease of the upper extremity is a rare entity.In this study ,we report our medical treatment protocol for symptomatic distal ulnar artery occlusion. INTRODUCTION The vascular patterns of the palmar arches and their interconnecting branches present a complex and challenging area. Improvements in microsurgical techniques have made a better understanding of vascular patterns and vessel diameters more important (1). CASE PRESENTATION Our case was a 72-year-old male. He was suffering from pain in the left hand and discoloration and coldness of the tips of 3, 4 and 5 digits for one month. Physical examination revealed no ulceration of this non-dominant hand (Figures 1&2). Only the left ulnar arterial pulse was detectable with sonic Doppler device and the remaining pulses were easily palpable. Clinical examination shows a positive Allen test for ulnar artery occlusion. Figure 1 Figure 1 Our medical treatment protocol for symptomatic distal ulnar artery occlusion 2 of 4 Figure 2 Figure 2 His past medical history was significant for Type 2 Diabetes Mellitus for 8 years that was regulated with oral antidiabetic agents. He also was an ex-smoker who quit smoking 10 years ago. Selective left upper extremity DSA revealed patent left subclavianaxillarybrachialand radial arteries (Figures 3&4). Figure 3 Figure 3 Figure 4 Figure 4 Ulnar artery was occluded at distal segment. Moreover, palmar arch was invisible and metacarpal arteries were occluded at multiple levels (Figures 5&6). Figure 5 Figure 5 Our medical treatment protocol for symptomatic distal ulnar artery occlusion 3 of 4 Figure 6 Figure 6 Taking these findings into account, our medical treatment strategy was as follows: Figure 7 He completed the late period after the onset of therapy with this ambulatory treatment protocol. His complaints of pain and discoloration completely faded away. His sensorimotor neurological status is normal. DISCUSSION Arterial occlusive disease of the upper extremity is most often due to posttraumatic occlusion of the ulnar artery. An embolic source of the ischemia should be considered most strongly when sudden ischemia or vasospasm is associated with atrial fibrillation or follows a myocardial infarction. Connective tissue disorders and several arteridities are infrequent causes of upper-extremity occlusive disease (2). Because damage to either the radial or the ulnar artery in the form of laceration or thrombosis can occur with no or minimal symptoms due to adequate collateral circulation, the prevalence of asymptomatic occlusions is unknown (3). Increased sympathetic tone from reflex vasospasm in the face of otherwise adequate collateral vessels may decrease perfusion sufficiently to cause ischemic symptoms and signs(3,4). Isolated ulnar artery occlusion is seldom the cause of digital tip necrosis (3). Only 5% of normal subjects had ulnar artery dominance in all digits(5). Arteriography still remains the reference standard for the evaluation of vascular insufficiency (3). Arteriography can be useful in the identification of upper extremity emboli and their source, and should include studies of the aortic arch, proximal subclavian artery, and digital arteries (6). References 1. Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res 2001;(383):41-6. 2. Zimmerman NB. Occlusive vascular disorders of the upper extremity. Hand Clin 1993 ;9(1):139-50. 3. Netscher DT, Janz B. Treatment of symptomatic ulnar artery occlusion. J Hand Surg [Am] 2008 ;33(9):1628-31. 4. Koman LA, Smith BT, Pollack FE, Smith TL, Pollack D, Russell GB. The microcirculatory effects of peripheral sympathectomy. J Hand Surg 1995;20:709–17. 5. Kleinert JM, Fleming SG, Abel CS, Firrell J. Radial and ulnar artery dominance in normal digits. J Hand Surg 1989;14: 504–8. 6. Maiman MH, Bookstein JJ, Bernstein EF. Digital ischemia: angiographic differentiation of embolism from primary arterial disease. AJR Am J Roentgenol 1981 ;137(6):1183-7. Our medical treatment protocol for symptomatic distal ulnar artery occlusion 4 of 4 Author Information Ufuk YETKIN Clinical Deputy Chief, Assoc. Prof. in CVS, Department of Cardiovascular Surgery(CVS), Izmir Ataturk Training and Research Hospital Berkan OZPAK Resident in CVS, Department of Cardiovascular Surgery(CVS), Izmir Ataturk Training and Research Hospital Tayfun GOKTOGAN Specialist in CVS, Department of Cardiovascular Surgery(CVS), Izmir Ataturk Training and Research Hospital Ismail YUREKLI Specialist in CVS, Department of Cardiovascular Surgery(CVS), Izmir Ataturk Training and Research Hospital Ali GURBUZ Clinic Chief, Assoc. Prof. in CVS, Department of Cardiovascular Surgery(CVS), Izmir Ataturk Training and Research Hospital