Prospective assessment of function and cold-intolerance following revascularization for hypothenar hammer syndrome.

Ulnar artery revascularization in hypothenar hammer syndrome has repeatedly been shown to reduce ischaemic symptoms, however with varying graft patency percentages. This study prospectively assesses the effect of revascularization surgery with a vein graft using validated questionnaires in seven patients. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Cold Intolerance Symptom Severity (CISS) questionnaires have been used to compare the preoperative and postoperative functionality and cold intolerance. All patients showed improvement in either functionality, or cold intolerance, or both from disabled to nearly normalized levels and resumed their occupation at final follow-up (mean of 28 months). Strikingly this was also the case in a patient with graft stenosis. Patients with the highest preoperative questionnaire scores showed most postoperative improvement. In conclusion, revascularization surgery seems to improve the symptomatology irrespective of graft patency. Questionnaires can be a valuable contribution to quantify and to follow the symptomatology in hypothenar hammer syndrome.

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.

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial.

BACKGROUND: Radial artery access is commonly performed for coronary angiography and invasive hemodynamic monitoring. Despite limitations in diagnostic accuracy, the modified Allen test (manual occlusion of radial and ulnar arteries followed by release of the latter and assessment of palmar blush) is used routinely to evaluate the collateral circulation to the hand and, therefore, to determine patient eligibility for radial artery access. We sought to evaluate whether a smartphone application may provide a superior alternative to the modified Allen test. METHODS: We compared the modified Allen test with a smartphone heart rate-monitoring application (photoplethysmography readings detected using a smartphone camera lens placed on the patient's index finger) in patients undergoing a planned cardiac catheterization. Test order was randomly assigned in a 1:1 fashion. All patients then underwent conventional plethysmography of the index finger, followed by Doppler ultrasonography of the radial and ulnar arteries (the diagnostic standard). The primary outcome was diagnostic accuracy of the heart rate-monitoring application. RESULTS: Among 438 patients who were included in the study, we found that the heart rate-monitoring application had a superior diagnostic accuracy compared with the modified Allen test (91.8% v. 81.7%, p = 0.002), attributable to its greater specificity (93.0% v. 82.8%, p = 0.001). We also found that this application had greater diagnostic accuracy for assessment of radial or ulnar artery patency in the ipsilateral and contralateral wrist (94.0% v. 84.0%, p < 0.001). INTERPRETATION: A smartphone application used at the bedside was diagnostically superior to traditional physical examination for confirming ulnar patency before radial artery access. This study highlights the potential for smartphone-based diagnostics to aid in clinical decision-making at the patient's bedside. Trial registration: Clinicaltrials.gov, no. NCT02519491.

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.

[Assessment of the radial and ulnar arteries hemodynamic changes by ultrasound in patients with primary palmar hyperhidrosis after thoracic sympathetic block].

Objective: To evaluate the value of radial and ulnar arteries hemodynamic changes by ultrasound in patients with primary palmar hyperhidrosis after thoracic sympathetic block. Methods: This was a prospective study, from January 2016 to September 2016, 23 patients with primary palmar hyperhidrosis were admitted to the First Hospital of Jiaxing City, Zhejiang Province, 92 arteries of these patients who underwent thoracic sympathetic block were enrolled into this study. Diameters, peak systolic velocity (PSV), end diastolic velocity (EDV) and resistive index (RI) of the radial and ulnar arteries were examined one day before and after the operation by color Doppler ultrasound. Spectral waveforms of these arteries were observed, and palms temperature (T), oxygen saturation (SpO(2)), perfusion index (PI) were also measured. Diameters, PSV, EDV, RI, T, SpO(2) and PI of the patients with PH were compared before and after the surgery. The effect of operation was also evaluated. Results: Before surgery, diameters and EDV of the radial and ulnar arteries of the patients with PH were(2.12±0.36) mm, (1.50±0.32) mm, (4.90±1.84) cm/s, (4.71±1.65) cm/s, respectively, after surgery, the diameter of the RA, UA and EDV were (2.45±0.54) mm, (1.87±0.44) mm, (9.37±1.69) cm/s and (9.12±1.54) cm/s, which were significantly increased.Before surgery, RI of the RA and UA of the patients were (0.85±0.05), (0.97±0.07) , respectively, after surgery, RI of the RA and UA were (0.57±0.04), (0.64±0.09), respectively, which were significantly decreased after surgery. The difference was statistically significant (t=-5.23, -2.33, -19.80, -14.68, 3.31, 3.48, all P<0.01). Before surgery, PSV of the RA and UA of the patients were (46.38±15.12) cm/s, (45.60±14.88) cm/s , respectively, after surgery, PSV of the RA and UA were (46.93±16.02) cm/s, (46.19±15.30) cm/s , respectively. The difference was not statistically significant (t=-0.23, -1.39, all P>0.05). Before surgery, T, SpO(2) and PI of the patients were(29.7±1.04) ℃, (93.24±2.23) %, (1.11±0.13) % , respectively, after surgery, T, SpO(2) and PI of the patients were (35.09±1.21) ℃, (98.10±1.34) %, (4.77±1.22)% , respectively. The difference was statistically significant (t=-20.174, -1.140, -23.601, all P<0.05). The symptoms of hyperhidrosis of the patients were disappeared immediately after the surgery in both hands. All of the patients were cured within 3 months and there was no severe complications. Conclusion: Thoracic sympathetic block increase Diameters and EDV but decrease RI of the radial and ulnar arteries of the patients with PH and increase the palms temperature. Artery diameters, EDV, and RI measured by ultrasound can be used as parameters to evaluate the effect of thoracic sympathetic block in patients with PH. It's objective, non-invasive and convenient.

[Assessment of the effects of surgical treatment options for cubital tunnel syndrome on the ulnar nerve by USG and EMG]. / Kübital tünel sendromunda cerrahi tedavi seçeneklerinin ulnar sinir üzerine etkilerinin USG ve EMG ile degerlendirilmesi.

OBJECTIVES: The morphology and functional results of the ulnar nerve were evaluated in patients treated with simple decompression and anterior subcutaneous transposition due to the diagnosis of cubital tunnel syndrome. PATIENTS AND METHODS: Thirteen elbows of 13 patients (8 males, 5 females; mean age 41 years; range 25 to 56 years) treated with simple decompression and anterior subcutaneous transposition due to the diagnosis of cubital tunnel syndrome were investigated. The involvement was on the dominant side in six patients. There was a 25° cubitus valgus deformity in one patient. No significant etiologic cause was found in the other patients. Seven patients were treated with anterior subcutaneous transposition and six with simple decompression. During the follow-ups, the atrophy magnitude, the new pressure areas and the intrinsic structure of the nerve tissue along the ulnar nerve path were evaluated by using soft tissue ultrasonography (USG). The flow rate of the artery supplying the ulnar nerve by Doppler mode USG and ulnar nerve conduction rate by electromyography (EMG) were assessed. Functional results were evaluated according to the Akahori's criteria and the modified Bishop scoring system. The average follow-up time was two years (range 12-44 months). RESULTS: In the Doppler USG examination, no arterial blood flow supplying the ulnar nerve was found in five of seven patients who underwent anterior transposition. A blood flow decrease of approximately 20 cm/s was found in two patients. A blood flow decrease of 10 cm/s on average was found in six patients who underwent simple decompression. There was a significant difference between the two groups (p<0.05). The control EMG revealed an increase of 9 m/s in the ulnar nerve conduction rate in the transposition group (p>0.05) and an increase of 17 m/s in the simple decompression group compared to the preoperative values (p<0.05). In seven patients who underwent anterior subcutaneous transposition, five excellent and two good results and an average of 8.2 points were achieved according to the Akahori's criteria and the modified Bishop scoring system, respectively. In six patients who underwent simple decompression, five excellent results, and one good result and an average of 8.1 points were achieved according to the Akahori's criteria and the modified Bishop scoring system, respectively. There was no statistically significant difference between functional results of both surgical techniques (p>0.05). CONCLUSION: Although the functional results of the cubital tunnel syndrome surgery are good, it must be noted that the blood supply to the nerve may be distorted, especially during anterior transposition. If there is no additional requirement, simple decompression may be considered as the first option.

Assessment of collateral circulation to the hand prior to radial artery harvest.

Assessment of collateral circulation to the hand is required prior to invasive procedures or harvesting of the radial artery (RA). A modified Allen's test (MAT) is commonly used to assess palmar arch collaterals. A variety of non-invasive methods including digital pressures, plethysmography, pulse oximetry and duplex ultrasonography are available to supplement physical examination. However, no consensus exists about the proper role of the MAT and the most appropriate non-invasive test (NIT) in this situation. Interpretation of the MAT and NIT findings are also controversial. This paper reviews the anatomy and the physiologic basis for the MAT and various NITs, the pros and cons of various NITs and recommendations for the assessment of collateral circulation to the hand prior to interventions directed at the RA.

Duplex in the assessment of the free radial forearm flaps: Is it time to change practice?

Radial forearm free flaps (RFFFs) are safe, but critical ischaemia of the hand has been described and is catastrophic. Every effort should therefore be made to improve the safety margin even further. Colour flow duplex ultrasound (US) is a simple, non-invasive and effective assessment tool. We compared it with Allen's test to identify serious vascular anomalies. We studied 121 patients who were listed to have a RFFF harvested, all of whom had both duplex US assessment and Allen's testing of the selected arm. The significance of differences in proportions was assessed using McNemar's test. Five of the 121 patients had an alternative flap selected as a consequence of the duplex assessment. A single flap failed. There were no ischaemic vascular complications that affected the hand.

Performance of coronary procedures through the transulnar access without assessment of the integrity of the deep palmar arch.

Occurrence of ischemic complications after transulnar coronary procedures is virtually absent. The presence of a complete deep palmar arch in approximately 95% of the population as well as the great capacity of the collateral circulation of the hand might justify these findings. We report the occurrence of complications in 62 patients submitted to coronary procedures through the transulnar approach, without assessment of the integrity of the deep palmar arch by the inverse Allen's test. The rate of asymptomatic occlusion of the ulnar artery was 3%, without any ischemic complication. We believe the performance of Allen's test is not necessary when using transulnar access.

Assessment of the radial artery and hand circulation by computed tomography angiography: a pilot study.

OBJECTIVES: The radial artery (RA) is increasingly being used as a coronary bypass graft. Results of a previous study using Doppler ultrasound and histopathologic examinations indicated that the RA has a higher incidence of preexisting intimal hyperplasia, medial calcification, and atherosclerosis than the internal thoracic artery. The aims of this study were to evaluate the use of computed tomographic angiography (CTA) to display hand collateral circulation, to define the criteria for an abnormal CTA test result, and to demonstrate usefulness of CTA as an alternative to conventional angiography for evaluation of the radial artery. MATERIALS AND METHODS: Sixteen patients scheduled for coronary artery bypass grafting entered this study. We performed 32 examinations of forearm and hand arterial anatomy in these patients. CTA was performed in patients with a normal Allen test result, except 1 patient who had a persistent median artery. Soft tissue density forehand roentgenography was performed in all patients before the CTA evaluation. There was no selection of patients in relation to patient characteristics. As a risk factor for radial artery calcification, 6 of the patients had diabetes mellitus, 6 had aortofemoral occlusive disease, and 4 had a history of smoking. RESULTS: Bilateral forearm arteries were visualized in all patients. Severe RA calcification was found in 1 patient, and distal occlusion was found in another patient. Focal RA calcification was noted in 2 patients. In the remaining patients no radial artery calcification or occlusion was noted. Anatomic variation of the upper limb arteries was shown in 2 patients; these variations were persistent median artery with absence of the radial and ulnar arteries and high bifurcation of the radial artery from the brachial artery. CONCLUSION: CTA is useful and safe for detection of radial artery calcific disease and assessment of the forehand circulation and its anatomic variations. Preoperative imaging of the RA is a means to avoid unnecessary forearm exploration or inadvertent use of a diseased conduit in coronary artery bypass candidates with multiple risk factors such as diabetes mellitus.

Preoperative assessment of the radial artery for coronary artery bypass grafting: is the clinical Allen test adequate?

BACKGROUND: The clinical Allen test (AT) is widely adopted as the only preoperative assessment of the hand collateral circulation before radial artery (RA) harvest as a coronary artery bypass graft. Nevertheless, in some cases it may be misleading because of clinically undetectable anatomic anomalies of the forearm arteries. METHODS: We evaluated the nondominant forearm arterial circulation by echo color Doppler (ECD) technique and by performing static and dynamic tests such as the AT, snuffbox test (SBT), and palmar arch test (PAT) in 150 patients who underwent elective coronary artery revascularization with a RA graft. RESULTS: Although the clinical AT was normal in all patients, in 8 patients (5.3%) preoperative ECD AT, SBT, and PAT did contraindicate RA harvesting. We did not harvest the RA in these patients. In the remaining 142 patients the RA was harvested. We did not observe any case of postoperative forearm or hand ischemia. We examined the blood flow to the hand in all patients at both 5 days and 24 months after surgery. In all patients ECD showed adequate hand perfusion and a significant increase of the peak flow velocity in the ulnar artery at both follow-up times. CONCLUSIONS: The clinical AT may be not sufficient to assess the hand collateral flow and the quality of the RA as a coronary artery bypass graft in at least 5% of patients. The ECD technique, performed during static and dynamic tests, does offer a safer and more objective preoperative noninvasive evaluation and it may have an important role also from the medicolegal point of view.

The radial hyperaemic response: a new and objective assessment of ulnar collateral supply to the hand.

The assessment of adequate ulnar collateral supply to the hand is mandatory prior to the harvest of the radial artery as a conduit for coronary artery bypass grafting. However, there is currently no one test which is widely used in all centres. We report a new and objective method of assessing ulnar collateral supply to the hand prior to harvest of the radial artery. This technique involves assessing the presence of a hyperaemic flow response to occlusion of the radial artery using an intraoperative transit time flowmeter. We found this technique to be objective and reliable, and would advocate its use in patients with a positive Allen's test.

Assessment of microvascular changes in Raynaud's phenomenon and connective tissue disease using colour doppler ultrasound.

OBJECTIVE: We used colour Doppler ultrasound (CDU) to differentiate primary from secondary Raynaud's phenomenon (pRP and sRP, respectively) and to assess digital vascular damage in patients with connective tissue disease (CTD). METHODS: Vascularity in the nailbeds of 15 healthy controls and 35 patients with CTD (systemic sclerosis or systemic lupus erythematosus) was quantified using a multi-D array transducer before and after cold and warm challenge, respectively. The results were compared with the clinically evaluated initial skin lesions. Vascularity was compared similarly between 10 pRP and 22 sRP patients. RESULTS: Vascularity at ambient temperature differed between healthy subjects and sRP patients as well as between healthy subjects and CTD patients without initial skin lesions. Patients with pRP had normal vascularity at ambient temperature but differed from healthy controls in response to a dynamic temperature challenge. CDU confirmed the clinical evaluation in 89.4% of the patients with RP and in 78.0% of the skin lesions. CONCLUSION: The novel CDU technique presented here makes it possible to discriminate between pRP and sRP and to quantify vascular changes in CTD patients.

Incidence and management of arterial emboli from hemodialysis graft surgical thrombectomy.

PURPOSE: To determine the incidence and significance of arterial emboli resulting from surgical thrombectomy/revision of hemodialysis grafts. This information may help in determining the significance and management of similar emboli resulting from percutaneous hemodialysis graft thrombolysis. PATIENTS AND METHODS: Patients undergoing surgical thrombectomy/revision of clotted hemodialysis grafts are studied with postoperative fistulography per institutional protocol whenever possible. For this retrospective study, all postoperative fistulograms from a 1-year period were reviewed for the presence of arterial emboli. Patients with documented arterial emboli were examined for evidence of hand/digital ischemia; only those patients with signs or symptoms of ischemia were treated. At clinical follow-up, repeated evaluation for hand/digital ischemia was performed. RESULTS: Ninety-one thrombectomy/revision procedures were performed during the study period. Postoperative fistulograms were obtained after 67 of these procedures in 32 patients. One patient complained of hand pain during dialysis prior to acquisition of the postoperative fistulogram. Arterial emboli were documented in eight patients (12%; brachial, n = 3; radial, n = 2; ulnar, n = 2; radial/ulnar, n = 1). The single symptomatic brachial embolus was percutaneously removed; no intervention was undertaken in the remainder. At mean follow-up of 14 months, no patient had developed hand or digital ischemia. Subsequent fistulograms demonstrated partial (n = 2) or complete (n = 2) resolution of the untreated emboli. CONCLUSION: Arterial emboli are a relatively common occurrence with surgical thrombectomy/revision. Conservative management appears to be indicated in asymptomatic patients.

The radial Chinese flap at the expense of the palmar radiocarpal arch. A case report.

The retrograde flow Chinese flap has been shown to be a useful cover for extensive losses of palm tissue. We report a case in which vascularization was based on the palmar radiocarpal arch, with angiographic verification, in view of the post-injury absence of palmar arches. Considering the results obtained, the technical modifications introduced with respect to earlier studies are described (flap pivoting 2 cm from the Lister tubercle), and the palmar anastomotic network of the carpal bones is proposed as a new end effective vascular axis in the preparation of retrograde flow antebrachial axial flaps with an intact volar radiocarpal region.

Preoperative vascular assessment: an aid to radial forearm surgery.

Twenty-three patients undergoing oral reconstructive surgery with radial forearm free flaps had a vascular assessment of the forearm preoperatively. Segmental upper limb pressures were measured and colour flow duplex visualization of forearm vessels and blood flow done. In 18 the blood pressure and flow were within normal limits, but five (22%) showed either unilateral or bilateral arteriopathy or aberrant vascular anatomy. Identification of pre-existing vascular disease helps to rationalize the selection of donor vessels, reduces the risk of ischaemic damage to the hand after disruption of the radial artery and may be of benefit in reducing the incidence of failure of free flaps.