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An Algorithmic Approach To The microsurgical Treatment Of Chronic Ischemia Of The Hand: A Review Of The Literature And Survey Of Treating Physicians
Stephanie Thibaudeau, MD, Patrick Gerety, MD, Scott Levin, MD.
University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE:
Autoimmune causes of chronic hand ischemia result in intractable pain and digital necrosis. Treatment of these conditions is poorly understood by both surgeons and physicians. This paper aims to define an algorithm for these patients.
METHODS:
1. A systematic search of the published literature was undertaken to identify surgical treatment of chronic hand ischemia.
2. A survey was sent to rheumatologists, vascular and hand surgeons at the senior author’s institution regarding their understanding of referral and treatment of patients with chronic hand ischemia.
RESULTS:
The literature review identified three surgical approaches: arterial bypass (11), periarterial sympathectomy (PAS) (15), and venous arterialization (5) (Figure 1). The 15 articles for PAS demonstrated pain relief in 86%, relief of cold intolerance in 80%, and ulcer healing in 84%. In the 11 articles for arterial bypass (96 patients), 9 articles reported a thrombosis rate of 6.4% and a limb salvage rate of 98%. Five venous arterialization articles (15 patients, 19 hands) reported 100% limb salvage.
In our survey, 79% of respondents felt they did not have a clear algorithm for the treatment of chronic hand ischemia. Only 21% of respondents reported treating a patient who had undergone venous arterializations.
CONCLUSION:
Our survey demonstrates that chronic ischemia of the hand is a challenge for treating physicians, many of whom are unaware of available surgical therapies. Our literature review demonstrates that limb salvage and symptomatic relief are possible. Based on these data and the senior author’s clinical experience, we propose a treatment algorithm.


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