Long-term results of ulnar and radial reconstruction with interpositional grafting using the deep inferior epigastric artery for chronic hand ischemia.

Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan-Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

Blood flow changes in the forearm arteries after ultrasound-guided costoclavicular brachial plexus blocks: a prospective observational study.

BACKGROUND: An increase in blood flow in the forearm arteries has been reported after brachial plexus block (BPB). However, few studies have quantitatively analysed the blood flow of the forearm arteries after BPB or have studied only partial haemodynamic parameters. The purpose of the present study was to comprehensively assess blood flow changes in the distal radial artery (RA) and ulnar artery (UA) after BPB performed via a new costoclavicular space (CCS) approach using colour Doppler ultrasound. METHODS: Thirty patients who underwent amputated finger replantation and received ultrasound-guided costoclavicular BPB were included in the study. The haemodynamic parameters of the RA and UA were recorded before the block and 10 min, 20 min, and 30 min after the block using colour Doppler ultrasound to determine the peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (Vmean), pulsatility index (PI), resistance index (RI) and area. The volumetric flow rate (VFR) was calculated using the formula Q = area×Vmean. The aforementioned parameters were compared not only before and after the BPB but also between the RA and UA. RESULTS: Compared with those of the respective baselines, there was a significant increase in the PSV, EDV, Vmean, area, and VFR and a significant decrease in the PI and RI of the RA and UA 10 min, 20 min, and 30 min post-block. The increase 30 min post-block in EDV (258.68 % in the RA, 279.63 % in the UA) was the most notable, followed by that in the Vmean (183.36 % in the RA, 235.24 % in the UA), and the PSV (139.11 % in the RA, 153.15 % in the UA) changed minimally. The Vmean and VFR of the RA were significantly greater than those of the UA before the BPB; however, there was no significant difference in the VFR between the RA and UA after the BPB. CONCLUSIONS: A costoclavicular BPB can increase blood flow in the forearm arteries. The RA had a higher volumetric flow rate than the UA before the BPB; however, the potential blood supply capacity of the UA was similar to that of the RA after a BPB. TRIAL REGISTRATION: This study was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/searchproj.aspx, clinical trial number: ChiCTR 1900023796, date of registration: June 12, 2019).

A Clampless Technique to Facilitate Successful End-to-End Anastomosis in Small Vessels With Spasm.

End-to-end anastomosis in small arteries can be challenging, especially when the stumps are in spasm after traumatic transection. We describe a novel technique to facilitate such anastomoses under local anesthesia, presenting a 24-year old patient who suffered complete traumatic transection of the left ulnar artery. After having found and prepared the proximal and distal stumps, a soft polyurethane feeding tube (La-med Healthcare, India) and a vein cannula were inserted in the proximal and distal stump, respectively, without using vascular clamps. The manipulation of the catheters offered excellent visualization and widening of the anastomotic line, enabling simultaneous infusion of heparinized saline or vasodilating agents. The anastomosis was completed with no stenosis and pulpable pulses were restored immediately postoperatively. At 1-month follow-up, the Allen test was normal with a normal regular flow of the ulnar artery at duplex ultrasound. The described technique ensures efficient sealing avoiding clamping, casts the small lumens, provides optimal visualization of the anastomotic aspects and prevents stenosis. We believe it should have a place in the surgeon's armamentarium.

Endovascular management of critical hand ischemia by 'palmar arch loop' technique.

INTRODUCTION: Critical hand ischemia with advancing gangrene of digits requires urgent intervention to salvage as much tissue as possible. The purpose of this study was to evaluate the efficacy of "palmar arch loop" technique for endovascular management of critical hand ischemia by establishing inline flow to the palmar arch via both radial artery and ulnar artery, in patients with failed antegrade recanalization. To the best of our knowledge, this is the first case series evaluating the efficacy of "palmar arch loop" technique, with retrograde percutaneous transluminal angioplasty of the involved radial artery and/or ulnar artery. MATERIAL AND METHODS: We retrospectively investigated 10 patients (60% female; mean age 42 ± 18 years; mean time of presentation post-acute event 24 ± 11 days) with critical hand ischemia undergoing endovascular intervention using "palmar arch loop" technique at a single center in northern India between April 2017 and March 2019. All patients were followed up at regular intervals (weekly for a month, fortnightly for 3 months, and then at 6 and 12 months) with clinical assessment and SpO2 measurement. Study end points were technical success rate, hand healing, and primary patency rate at one year. RESULTS: Causes for critical hand ischemia were iatrogenic injuries due to inadvertent intra-arterial injection in 50% (n = 5) and thromboembolic events in 50% patients (n = 5). Vessels involved were: both radial artery and ulnar artery along with the PA in 50%; radial artery and palmar arch in 30%; ulnar artery and palmar arch in 20%. All of them had total occlusion of the involved vessel (>2/3rd of total length) with occlusion/diffuse disease of palmar arch as well; 70% technical success rate was achieved ensuring inflow to palmar arch via both the arteries with improved flow distally to the common and proper digital arteries. Retrograde percutaneous transluminal angioplasty of radial artery in 50% (n = 5) and ulnar artery in 20% (n = 2) was done successfully by looping the guidewire across the palmar arch; 90% showed subjective improvement in pain with healing of the lesions and/or formation of clear line of demarcation with reversal of pregangrenous changes proximally. Out of the eight patients with gangrene of fingers, three underwent minor amputation of the gangrenous digits and five underwent auto-amputation of the gangrenous tissue with complete healing of the stump. Primary patency rate was 85.7% at one year. There was no access site-related complication or mortality in the follow-up period. CONCLUSIONS: Endovascular management of critical hand ischemia by "palmar arch loop" technique is an efficient technique to deal with occluded forearm vessels, particularly when antegrade recanalization fails. This technique, with good technical success and patency rates, is potentially a unique tool in the endovascular armamentarium for salvaging hand.

Ultrasound Detection of Calcinosis and Association With Ulnar Artery Occlusion in Patients With Systemic Sclerosis.

OBJECTIVE: To investigate the ability of ultrasound (US) compared to radiographs to detect calcinosis in hands/wrists of patients with systemic sclerosis (SSc), and to assess US markers of pathologic perfusion. METHODS: Patients with SSc were evaluated for calcinosis in the hands/wrists by radiograph and US. The presence or absence of calcinosis was recorded by patient, hand, and anatomic zone; sensitivity and specificity for calcinosis detection by US versus radiographs was determined. Bilateral US vascular measurements of ulnar artery occlusion (UAO) and finger pulp blood flow (FPBF) were obtained. For each hand, associations between markers of pathologic blood flow (UAO, FPBF, and a composite severity score of UAO and FPBF) and the presence of calcinosis were assessed using generalized estimating equations. RESULTS: Of 43 patients with SSc (19 diffuse, 24 limited), 39.5% had calcinosis on radiographs compared to 30.2% on US. Sensitivity and specificity for US, respectively, were 61% and 95% by zone, 78% and 98% by hand, and 76% and 100% by patient. UAO was seen in 30% and 28% of left and right hands, respectively; FPBF was absent in ≥1 digit of the left and right hands in 49% and 44%, respectively. UAO was associated with radiograph-identified calcinosis by hand (odds ratio [OR] 8.08 [95% confidence interval (95% CI) 2.45-26.60], P < 0.001), whereas FPBF and the composite severity score were not significant. UAO was associated with calcinosis even in the absence of digital ulcers (OR 33.00 [95% CI 3.39-321.09], P = 0.003). CONCLUSION: US was sensitive and highly specific in detecting calcinosis in SSc. UAO was strongly associated with radiograph-identified calcinosis.

Real-World Usage of the WavelinQ EndoAVF System.

BACKGROUND: Dependent on existing deep to superficial perforating venous branches, the WavelinQ EndoAVF System is a novel technique used to create an arteriovenous fistula (AVF) between ulnar or radial veins and concomitant arteries for dialysis access. We sought to examine a single center's success rates and short-term follow-up using this device. METHODS: All consecutive patients undergoing placement of a WavelinQ AVF from October 2018 to July 2019 were included. Preoperative/intraoperative variables including demographics, preoperative/postoperative duplex ultrasonography, success rate of procedure, and subsequent endovascular/surgical procedures were obtained. Descriptive statistics and comparison of groups requiring subsequent intervention were performed. RESULTS: Thirty-five patients underwent placement of the WavelinQ AVF, with 32 (91%) patients having at least one documented follow-up. These patients were predominantly male (23/32, 72%) with an average age of 60.2 and 23 of 32 (72%) patients were on dialysis. Initial fistula creation success rate was 100%. Average procedural length was 120 min, fluoroscopy time 9.6 min, and contrast usage 52.2 mL. Eight of 32 (25%) patients had perioperative complications (3 hematomas, 3 contrast extravasations, 1 resolved vessel spasm all resolving spontaneously, and 1 pseudoaneurysm requiring surgical repair). Thirteen of 32 (41%) patients underwent subsequent endovascular interventions to assist with maturation [9/32 (28%) branch coiling, 5/32 (16%) angioplasty/stenting, and 3/32 (9%) access thrombectomy] and 4 of 32 (13%) patients required subsequent surgical interventions (1 pseudoaneurysm repair, 1 revision of fistula, and 2 definitive AVF creation in thrombosed grafts). The majority of accesses (30/32, 94%) were ulnar-ulnar fistulas and overall patency at average follow-up of 73 days was 88% (28/32) with average brachial artery inflow volume of 1,078 cc/min and average cephalic vein (18/32) outflow volume of 447 cc/min. Eleven of 23 (48%) patients on dialysis were successfully using the EndoAVF at follow-up. CONCLUSIONS: The WavelinQ AVF system has a high initial procedural success rate, although a significant portion of patients require subsequent endovascular procedures to aid in maturation. Further work on determining factors predictive of need for reintervention is necessary.

Hypothenar Hammer Syndrome with Ulnar Nerve Neuropathy.

Hypothenar hammer syndrome is a rare medical condition that is usually associated with repetitive hand trauma. In this article, we delineate the importance of the nerve conduction velocity study to help determine objectively whether neuropathy is significant to the point that surgical means should be considered in absence of obvious ischemic change.

Invasive Assessment of the Human Arterial Palmar Arch and Forearm Collateral Function During Transradial Access.

BACKGROUND: The present study aimed to quantitatively measure the pressure-derived function of the palmar arch and forearm arterial collateral circulation during transradial access. METHODS AND RESULTS: Palmar arch and forearm collateral function was determined using radial artery pressure signals in the nonobstructed vessel and during brief manual occlusions of the more proximal radial artery and of the radial plus ulnar arteries. Collateral flow index (CFI), the ratio of mean occlusive divided by mean nonocclusive arterial blood pressure, both subtracted by central venous pressure, was determined for CFI during radial artery occlusion (CFIrad) and CFI during radial plus ulnar artery occlusion. Before invasive CFI measurements, arterial palmar arch and forearm function was tested noninvasively by the modified Allen test (MAT). Two hundred fifty patients undergoing transradial access coronary angiography were included in the study. CFIrad was equal to 0.802±0.150 (95% CI, 0.783-0.820). CFI during radial plus ulnar artery occlusion was equal to 0.424±0.188 (95% CI, 0.400-0.447). There was an inverse linear relation between CFIrad and MAT in seconds (s): MAT=64-63×CFIrad ( r2=0.229; P<0.0001). Two hundred eleven patients had a normal and 39 patients an abnormal (>15 seconds) MAT. The group with normal MAT had a CFIrad of 0.830±0.111, and patients with abnormal MAT had a CFIrad of 0.648±0.224 ( P<0.0001). CONCLUSIONS: Direct invasive hemodynamic assessment of the palmar arch and forearm arterial function reveals collateral supply to the briefly occluded in comparison to the patent radial artery of 0.802. During external occlusion of both radial and ulnar artery, CFI amounts to an unexpectedly high value of 0.424.

Comparison of forearm versus upper arm basilic transposition arteriovenous fistulas demonstrates equivalent satisfactory patency.

OBJECTIVE: In accordance with the Kidney Disease Outcomes Quality Initiative recommendations, attaining autogenous hemodialysis access, specifically via creation of radiocephalic arteriovenous fistulas (AVF), brachial-basilic (BB)-AVF, or brachial-cephalic AVFs, is preferred for mortality and morbidity benefits over catheter access in patients with end-stage renal disease. The aim of this study is to determine the suitability of forearm basilic vein transposition (FBVT) fistulas as an alternative access option by comparing outcomes with those of BB-AVFs. METHODS: All patients who underwent creation of FBVT between 2007 and 2015 were identified retrospectively in the electronic medical record and compared with a sample of patients undergoing BB-AVF placement during this time. Access patency was examined using Kaplan-Meier methods and Cox proportional hazards regression. RESULTS: We included 34 patients with FBVT (median age, 54 years; 67.6% male) and 49 with BB-AVF (median age, 57 years; 42.9% male) in this study. There were no significant differences in comorbid conditions between the two groups, with the exception of hyperlipidemia (29.4% FBVT vs 53.1% BB-AVF; P = .03). Although those with FBVT were more likely to have had previous permanent access attempts (70.6% vs 38.7%; P = .002), and access attempts on the same extremity (44.1% vs 24.4%; P = .04), there were no significant differences in primary patency (46.9% vs 53.3%; P = .6), primary-assisted patency (65.6% vs 73.3%; P = .5), or secondary patency (68.8% vs 82.2%; P = .2) at 1 year when compared with BB-AVF. The risk of loss of patency was not statistically different for FBVT as compared with BB-AVF (hazard ratio, 1.37; 95% confidence interval 0.65-2.88; P = .4). This risk did not vary for those who had previous access on the same arm (interaction P = .8). Four fistulas in each group failed to mature. Only one infectious complication was identified in the FBVT group. CONCLUSIONS: No prior studies have directly compared outcomes of FBVTs with BB-AVFs at 1 year or longer. Despite the increased difficulty of harvesting the forearm basilic vein, particularly in patients who have had prior access attempts, there was no significant difference in patency between FBVTs and BB-AVFs. FBVTs are a reasonable option for hemodialysis access, particularly in patients without adequate cephalic veins or who previously failed radiocephalic fistula attempts.

Ulnar Artery Thrombosis Presented with Unilateral Raynaud's Phenomenon Findings after Long-Term Intensive Handicraft Activity: Hypothenar Hammer Syndrome.

BACKGROUND: Hypothenar hammer syndrome (HHS) is an uncommon vascular syndrome of upper extremity. HHS should be considered in patients who are presented with digital ischemia. Distal ulnar artery compression at the level of Guyon's canal with trauma results in thrombus or aneurysm. It may be observed after repetitive chronic trauma or acute blunt trauma to hypothenar eminence. Middle-aged male laborers, smokers, and dominant hands are affected frequently. Hand pain, discoloration or ulceration of digits, cold intolerance, hypothenar pulsatile mass, hypothenar weakness, and numbness are significant clinical findings. CASE CHARACTERISTICS: In this report, we presented a 37-year-old woman complaining with intermittent hand pain, paleness, and cyanosis at third, fourth, and fifth fingers of the right hand. She had no blunt trauma to her hand but intense amount of needle lace with her hands. Doppler ultrasonography revealed ulnar arterial thrombus at right Guyon's canal level. CONCLUSIONS: She was diagnosed as HHS secondary to intense needlework. A calcium channel blocker and low-dose aspirin were prescribed to her, and avoidance of hand traumas was suggested. These interventions relieved digital ischemia symptoms on her hand.

Altered Hand Temperatures Following Transradial Cardiac Catheterization: A Thermography Study.

BACKGROUND: There is concern about potential detrimental effects of transradial access (TRA) on radial artery structure, endothelial and hand function. This thermography study evaluated TRA impact on hand microvascular perfusion. METHODS AND RESULTS: We prospectively measured hand thermography, radial and ulnar artery size and blood flow velocities in both catheterization and non-catheterization hands at baseline and 30-days after TRA in 158 patients. There were no differences in radial or ulnar arterial diameters or velocities pre- and post-TRA in catheterization and non-catheterization hands (p = NS). The absolute total hand thermography values post-TRA were increased in both catheterization and non-catheterization hand (pre-TRA 30.4 ±â€¯2.9 vs. post-TRA 31.6 ±â€¯2.6 p < 0.01; pre-TRA 30.2 ±â€¯2.9, post-TRA 31.6 ±â€¯2.6 p < 0.01, respectively). After ulnar artery occlusion, hand temperatures decreased in both catheterization and non-catheterization hands, both pre- and post-TRA and were similar in the catheterization and non-catheterization hands (p = NS). Total hand temperature decreased with ulnar artery occlusion and was significantly attenuated post-TRA (p < 0.001 both catheterization and non-catheterization hands). CONCLUSIONS: TRA is associated with temperature changes in both catheterization and non-catheterization hands at one month after the index procedure. These changes likely represent a systemic response to local TRA stimulus.

Evidence of macro- and micro-angiopathy in scleroderma: An integrated approach combining 22-MHz power Doppler ultrasonography and video-capillaroscopy.

OBJECTIVE: We aimed to study in SSc patients macrovascular involvement by using power Doppler ultrasound (PDUS) and microvascular one by PDUS and nailfold video-capillaroscopy (NVC) and to examine the association between history of digital ulcers (HDU) and imaging (PDUS and NVC) parameters. METHODS: NVC and PDUS were systematically performed in 106 consecutive SSc patients at the 3rd and 4th finger of the dominant hand after exclusion of ulnar artery occlusion (UAO). 22 MHz PDUS measurements included nailbed and fingertip qualitatively graded, and resistivity index (RI) of ulnar and radial proper digital arteries. Capillary number/mm was calculated by NVC on the same digits examined by PDUS. RESULTS: Vascularization at fingertip and nailbed showed a good correlation between them and to capillary number. RI, representative of macrovascular involvement, did not correlate to microvascular involvement as assessed by PDUS and NVC. RI and capillary number at NVC showed significant correlation to HDU while fingertip and nailbed vascularization as assessed by PDUS did not. As such, PDUS and NVC provide different and potentially complementary information on SSc-related peripheral macro- and micro-vascular involvement. CONCLUSION: Macro- and micro-vascular involvement in SSc patients are different processes and are not present at the same time in every patient. Thus, both these aspects should be carefully evaluated in SSc patients.

Ulnar Artery Thrombosis Following Tranexamic Acid Administration for Craniosynostosis Repair.

Pediatric craniosynostosis repair with cranial vault reconstructive surgery can be associated with significant blood loss. Tranexamic acid (TXA), an antifibrinolytic agent, has been shown to decrease blood loss and transfusion volume in craniofacial surgery. Nonetheless data regarding the safety of TXA remains limited. The authors describe a case of ulnar artery thrombosis following ulnar arterial line placement in a patient who received TXA for cranial vault reconstructive surgery.

Treatment of critical hand ischemia via orbital atherectomy and focal force balloon angioplasty: A mini-review.

Calcified lesions in below-the-elbow (BTE) arteries are common in patients with diabetes or end-stage renal disease and can lead to critical hand ischemia (CHI). Treatment of calcified lesions with atherectomy has proved useful in the lower extremities, however, atherectomy in the upper extremities and especially BTE, is not typically considered due to the small vessel size. We review and discuss these studies along with other CHI-related articles and also present a case of a severely calcified ulnar artery lesion treated with orbital atherectomy and plain Chocolate balloon angioplasty.

Upper arm basilic vein elevation as a solution for forearm ulnar-basilic arteriovenous fistulae with cannulation problems.

BACKGROUND: Ulnar-basilic arteriovenous fistula is an alternative option when a radiocephalic arteriovenous fistula is not feasible. We review our technique of basilic vein transposition in the upper arm for difficult to puncture forearm ulnar-basilic non-transposed arteriovenous fistulae. TECHNICAL NOTE: Three patients were referred for forearm ulnar-basilic arteriovenous fistulae with difficult cannulation where the forearm basilic vein was left in situ (non-transposed). Surgeon performed ultrasound examination confirmed a patent arteriovenous fistula with adequate diameter and flow, draining to the basilic vein in the forearm and into the upper arm. Recurrent new and resolving hematomas were present surrounding the forearm basilic vein resulting from difficult cannulation issues and problems maintaining needle position due the posterior-medial ulnar-basilic arteriovenous fistula position and mobility of the non-transposed forearm basilic vein. A basilic vein transposition elevation procedure was performed in the upper arm starting at the level of the elbow to a few centimeters below the axilla. Branches of the dilated basilic vein were ligated, the median cutaneous nerve was preserved, and the vein was elevated from its native position to a superficial and anterior location. Although difficult, dialysis access had been continued in the forearm during a brief period and none required catheter placement. Reliable dialysis access was successfully initiated using the newly transposed basilic vein in the upper arm 3-4 weeks after the procedure, maintaining arterial inflow based on the original ulnar-basilic arteriovenous fistula anastomosis at the wrist. None of the patients required further interventions with follow-up of 8, 15, and 22 months.

Long-term outcomes of the 'primary extension technique' in the prevention of Steal syndrome.

PURPOSE: To report our 13 years of experience with the 'primary extension technique' for the prevention of dialysis-associated steal syndrome. METHODS: All diabetic patients undergoing upper arm autogenous elbow fistula formation using the primary extension technique between September 2001 and September 2014 at a single centre were included. At follow-up all patients were evaluated for patency, adequacy of needling and the presence or absence of steal symptoms. In primary extension technique, the fistula is formed by anastomosing the median cubital vein with the proximal radial or ulnar artery just below the brachial artery bifurcation. RESULTS: In total, 64 operations of the primary extension technique were included in this study. All patients were diabetic. Primary failure was 5%, follow-up 23-84 months. Nine patients (14%) developed cephalic vein thrombosis. In these cases, the basilic vein was successfully transposed to the existing fistula. In eight patients (12.5%), the cephalic vein required superficialisation. In three patients, the flow was preferentially into the basilic vein with poor maturation of cephalic vein. Of these three patients, there was a small proximal cephalic vein in one patient and stenosis in the other two patients. One patient who developed dialysis-associated steal syndrome is included in the results as they were listed for primary extension technique fistula formation but in fact did not have their fistula formed using primary extension technique. Instead, the anastomosis was formed proximal to the bifurcation of the brachial artery. Symptoms improved with revision of the fistula. CONCLUSION: Our 13-year experience demonstrates that the primary extension technique is a safe and effective procedure for fistula formation. Patency rates are comparable to brachio-cephalic and brachio-basilic fistulas and primary extension technique is effective in the prevention of dialysis-associated steal syndrome.

Reactive hyperemia-peripheral arterial tonometry is useful for assessment of not only endothelial function but also stenosis of the digital artery.

BACKGROUND: Although reactive hyperemia-peripheral arterial tonometry (RH-PAT) is widely used for assessment of endothelial function, RH index (RHI) cannot be measured in some cases when pulse wave amplitude (PWA) is very low. Decrease in PWA is mainly caused by proper palmar digital artery (PPDA) stenosis. The purpose of this study was to evaluate the relationship between PWA measured by RH-PAT and stenosis of the PPDA measured by digital subtraction angiography and to evaluate the limitation of assessment of endothelial function measured by RHI in patients with PPDA stenosis. METHODS: We measured baseline PWA in 51 fingers including the first to third fingers of both hands in 10 patients who had PPDA stenosis and in 66 fingers that were the first fingers of both hands in 33 subjects who had no PPDA stenosis. Severe stenosis was defined as over 75% by lower percent diameter stenosis between two PPDAs in a finger. RESULTS: PWA was significantly correlated with stenosis of the digital artery (r=-0.55; P<0.0001). A PWV value of 300mV was the optimal cut-off value for severe stenosis (sensitivity, 84.0%; specificity, 88.5%). Log RHI was significantly lower in patients with PPDA stenosis than in subjects without PPDA stenosis (0.33±0.27 versus 0.73±0.27, P=0.007). CONCLUSIONS: RH-PAT may be useful for assessment of not only endothelial function but also PPDA stenosis. RHI may be underestimated in patients with PPDA stenosis. We should pay attention to low baseline PWA when measuring RHI. CLINICAL TRIAL REGISTRATION INFORMATION: URL for clinical trial: http://UMIN; registration number for clinical trial: UMIN000003409.

Hypothenar hammer syndrome: caused by a muscle anomaly? A case report with review of the literature.

The hypothenar hammer syndrome (HHS) is a rare entity of secondary Raynaud's phenomenon. The blunt hypothenar trauma causes a lesion of the vessel wall with a consecutive thrombosis or aneurysm of the ulnar artery at the Guyon's canal. Different risk factors are discussed such as nicotine abuse, or a muscle anomaly in the Guyon's canal. To date, there are five case reports published about muscle anomalies and HHS. We present a case of a 51-year-old shipbuilder with a unilateral HHS on his right dominant hand with a bilateral muscle anomaly. We successfully treated the patient by resection of the aneurysm without a resection of the atypical muscle.

Variability of forearm collateral circulation: An observational study of serial hand plethysmography testing.

OBJECTIVES: Evaluation of plethysmography as a reliable triage tool to access collateral circulation in the hand prior to transradial access. BACKGROUND: Hand plethysmographic testing has been used for access site triage prior to cardiac catheterization despite a lack of data supporting its result's stability. METHODS: Cohort of consecutive outpatients presenting for evaluation prior to cardiac catheterization underwent hand plethysmographic testing at the beginning of the office visit and before discharge. Demographics and clinical data was recorded. RESULTS: Hands (N = 887) in 445 patients were evaluated using the Barbeau plethysmography technique. Barbeau Test (BT) patterns A, B, C, and D were observed in 58%, 30%, 8% and 4% on initial evaluation. On preliminary evaluation, 780 (88%) hands had a "low-risk" pattern (A or B) and 107 (12%) hands had a "high-risk" pattern (C or D). Repeat evaluation performed 50 ±â€¯26 min later revealed a 'low-risk' pattern in 809 (91%) hands with 78 (9%) of hands showing a persistent "high risk" pattern. In 29 (27%) high-risk hands, spontaneous conversion to pattern B within <1 h occurred. Reverse Barbeau Test (RBT) at baseline showed pattern A, B, C and D in 95.9%, 2.8%, 1% and .4% respectively. There was no significant change in RBT upon follow-up evaluation. Strength of the radial artery pulsation was significantly associated with the pattern of RBT and the strength of ulnar pulsation was associated with the results of the BT. CONCLUSIONS: Plethysmographic testing of forearm circulation demonstrates variability over short intervals suggesting poor reliability for access site triage.