Positive Results Seen with Angioplasty for Critical Hand Ischemia

MIAMI BEACH, FLA.—Balloon angioplasty is safe and feasible in patients with critical hand ischemia (CHI), producing pain relief in more than 90% of cases, according to the results of a small patient series presented at TCT 2012.

Zoltán Ruzsa, MD, of Semmelweis University, Budapest, Hungary, and colleagues conducted a small prospective study looking at percutaneous transluminal angioplasty in 21 patients with CHI due to axillary-brachial and pure below-the-elbow disease. The mean age of the patients was 72 years.

Patients had CHI due to both subacute occlusion (29%) and chronic disease (71%). The researchers performed multilevel (38%), unilevel (62%) and parallel (14%) dilations.

High success, symptom alleviation

Treatment with percutaneous transluminal angioplasty resulted in a technical success rate of 95% with just one patient experiencing a vascular complication — radial artery perforation that was successfully treated with a compression bandage.

Patients with subacute CHI underwent mechanical and aspiration thrombectomy prior to angioplasty (n=6; 100%) and stenting (n=3; 50%). Angioplasty was performed in all patients with chronic disease (n=15; 100%), with stenting required in 40%.

There were no major adverse events during the follow-up period. However, two patients had to undergo secondary procedures due to symptomatic restenosis.

All but one patient experienced relief of pain (n=20; 95%), and the hand-healing rate for those with gangrene or non-healing ulcers (n=5) was 100%.

Informing treatment decisions

To date, there have been few publications investigating CHI and those include mainly case reports, according to Ruzsa. With these results, Ruzsa and colleagues have begun to shed light on the complexity of CHI and hope that the data will begin to inform clinical decision making in patients with the condition.

“Angiographically, the surprising thing [about the data] was the complexity of the forearm circulation and its resistance against hand ischemia,” Ruzsa told TCT Daily. “The hand was working like the below-the-knee circulation and the interosseous artery gave many collaterals to the radial and ulnar artery; in many cases, the hand ischemia developed only when these three arteries were simultaneously ill or when the radial artery occlusion occurred beside an incomplete palmar arch.”

Data also revealed interesting differences in the onset of CHI in patients with subacute vs. chronic disease.

“CHI developed sub-acutely in many cases due to embolism from the heart or proximal aneurysm,” Ruzsa said. In these cases, symptoms began some weeks after the embolism and a detailed clinical history and examination were necessary to rule out the embolism and start with mechanical thrombectomy.

In contrast, other patients developed CHI some years after a transradial intervention with progression of atherosclerosis. CHI immediately after transradial intervention was uncommon.

Moving forward, Ruzsa and colleagues hope to investigate a larger patient population and to gain increased understanding about the pathogenesis of CHI. Also needed is a long-term investigation into the use of drug-eluting balloons and DES in the treatment of the condition.

Study details

Of the 21 patients included in the study, 16 had pain at rest, two had non-healing ulcer and three had gangrene. Angioplasty was performed in the axillary (n=6), brachial (n=12), radial (n=5), ulnar (n=8) and interosseous (n=1) arteries and the palmar arch (n=2).