Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC.
J Vasc Surg. 2014 Aug;60(2):410-7. doi: 10.1016/j.jvs.2014.02.005. Epub 2014 Mar 18.
Limited evidence exists to guide clinical management of acute finger ischemia (AFI). To further inform diagnostic evaluation and decision making, we evaluated anatomic findings, procedural management, and amputation-free survival in an institutional cohort of patients with AFI.
Consecutive patients undergoing transfemoral upper extremity angiography for AFI were identified. Clinical, laboratory, and procedural data were collected retrospectively from medical records, and arteriograms were reviewed to characterize anatomic findings. Telephone interviews were used to determine long-term outcomes, and additional symptomatic assessments (Symptom Severity and Functional Status scale, the Cold Sensitivity Severity scale, and the McGill Pain Severity Scale) were available in a subgroup of patients. Outcomes included anatomic findings, use of thrombolysis, complications, and amputation-free survival. Descriptive statistics and survival analysis were used to evaluate results.
Thirty-five patients (54% women) were analyzed with a median follow-up of 13.7 months. Symptom duration at time of presentation ranged from 1 to 28 days, and seven patients had tissue loss or gangrene, or both. Mean age was 47.7 ± 12.2 years. Baseline characteristics included smoking in 22 (65%), connective tissue disorder in 11 (31%), and history of repetitive hand trauma in 10 (29%). The most frequent anatomic location of arterial pathology identified during angiography was distal to the wrist (n = 32), including eight ulnar/radial aneurysms; upper arm (n = 3) and forearm (n = 8) lesions were less common. Sixteen patients were treated with catheter-directed thrombolysis, of which eight (50%) had interval anatomic improvement on repeat angiography. Procedure-related adverse events associated with angiography included bleeding (n = 3) and pseudoaneurysm (n = 1). Eleven of 35 patients had subsequent surgical revascularization at a median of 15 days after angiography. Estimated (standard error) amputation-free survival was 0.88 (0.07) at 1 month and 0.84 (0.08) at 6 months among patients without tissue loss or gangrene. Estimated 60-day amputation-free survival was 0.84 (standard error, 0.08). Overall amputation-free survival was similar between patients managed with vs without thrombolysis (P = .61), but subgroup analysis of those patients without tissue loss or gangrene at the time of presentation revealed a trend toward improved amputation-free survival with use of thrombolysis, with 60-day amputation-free survival of 0.92 vs 0.75 (P = .12). Persistent late symptoms were present in 17 patients (48.6%) at the last follow-up and were generally characterized as mild by functional and pain scale assessments.
Angiography performed for AFI frequently identifies distal occlusive disease, and catheter-directed thrombolysis may expand revascularization options in select patients.
急性手指缺血（AFI）的临床管理指南有限。为了进一步指导诊断评估和决策，我们评估了机构队列中 AFI 患者的解剖学发现、程序管理和无截肢生存率。
确定了因 AFI 而行经股上肢血管造影的连续患者。从病历中回顾性收集临床、实验室和程序数据，并对血管造影进行审查以描述解剖学发现。通过电话访谈确定长期结果，并在亚组患者中进行了其他症状评估（症状严重程度和功能状态量表、冷敏严重程度量表和麦吉尔疼痛严重程度量表）。结果包括解剖学发现、溶栓的使用、并发症和无截肢生存率。使用描述性统计和生存分析评估结果。
分析了 35 名（54%为女性）患者，中位随访时间为 13.7 个月。就诊时症状持续时间为 1 至 28 天，7 名患者有组织损失或坏疽，或两者兼有。平均年龄为 47.7 ± 12.2 岁。基线特征包括吸烟 22 例（65%）、结缔组织疾病 11 例（31%）和手部重复创伤史 10 例（29%）。血管造影中最常见的动脉病变部位位于腕关节远端（n = 32），包括 8 例尺桡动脉动脉瘤；上臂（n = 3）和前臂（n = 8）病变较少见。16 名患者接受了导管定向溶栓治疗，其中 8 名（50%）在重复血管造影时有间隔解剖学改善。与血管造影相关的程序相关不良事件包括出血（n = 3）和假性动脉瘤（n = 1）。血管造影后中位 15 天，35 名患者中有 11 名随后进行了外科血运重建。无组织损失或坏疽的患者在 1 个月和 6 个月时的估计（标准误差）无截肢生存率分别为 0.88（0.07）和 0.84（0.08）。60 天无截肢生存率的估计值为 0.84（标准误差为 0.08）。无组织损失或坏疽的患者与接受溶栓治疗的患者之间的总体无截肢生存率相似（P =.61），但在无组织损失或坏疽的患者亚组分析中，溶栓治疗有改善无截肢生存率的趋势，60 天无截肢生存率为 0.92 比 0.75（P =.12）。17 名患者（48.6%）在最后一次随访时仍存在持续的晚期症状，功能和疼痛量表评估通常将其特征描述为轻度。
AFI 行血管造影常可发现远端闭塞性疾病，导管定向溶栓可能为部分患者扩大血运重建选择。
