Shukla Harshal, Yaghdjian Vicken, Koleilat Issam
Surgical Services/Anesthesiology, Department of Pharmacy, Montefiore Medical Center-Einstein Campus and The University Hospital for Albert Einstein College of Medicine, Bronx, NY, USA.
Surgical Services/Anesthesiology Department of Pharmacy, Montefiore Medical Center-Moses Campus and The University Hospital for Albert Einstein College of Medicine, Bronx, NY, USA.
SAGE Open Med Case Rep. 2018 Jan 4;6:2050313X17748866. doi: 10.1177/2050313X17748866. eCollection 2018.
Hypothenar hammer syndrome is a cause of symptomatic ischemia of the hand secondary to the formation of aneurysm or thrombosis of the ulnar artery in the setting of a complete or incomplete palmar arch. Acute occlusive thrombus or embolus of the hand represents a complex problem that often may require immediate surgical intervention. We report a case of acute unilateral arterial hand ischemia requiring catheter-directed thrombolysis with Alteplase therapy in a patient with acute occlusive arterial thrombosis of the left ulnar artery. A catheter-directed thrombolytic regimen consisted of Alteplase 1 mg/h for 24 h, and heparin was infused through the sheath side arm at a rate of 500 units per hour for resolution of the thrombus and improvement in symptoms. A former truck driver presented with worsening pain and subsequent development of significant cyanosis with early gangrenous changes of the left second and third fingertips. He had significant callous of the hypothenar eminence and reported that his left hand was not only his "driving" hand but also a cane has been used in his left hand to ambulate. Initial angiogram revealed only ulnar artery occlusion at the wrist with reconstitution just distal to the hypothenar eminence. After 24 h of the initiation of thrombolysis, repeat angiography revealed resolution with a widely patent ulnar artery. His symptoms and the color of his digits immediately improved, and within a few months, his hand had normalized. The patient had no clinical sequelae of thrombolytic therapy. Catheter-directed thrombolytic therapy in situations of acute occlusive thrombus of the hand may provide a therapeutic option for patients with suspected hypothenar hammer syndrome. However, thrombolytic therapy carries risk of significant hemorrhagic complications. Before initiating therapy, careful judgment about the possibility for bleeding risk is required. This provides for a minimally invasive alternative to open surgical revascularization especially in the absence of underlying correctable anatomic defect such as aneurysm.
小鱼际锤状指综合征是在掌弓完全或不完全的情况下，尺动脉形成动脉瘤或血栓继发手部症状性缺血的一个原因。手部急性闭塞性血栓或栓子是一个复杂的问题，通常可能需要立即进行手术干预。我们报告一例急性单侧手部动脉缺血患者，该患者因左尺动脉急性闭塞性血栓形成，需要使用阿替普酶进行导管定向溶栓治疗。导管定向溶栓方案为阿替普酶1毫克/小时，持续24小时，并通过鞘侧臂以每小时500单位的速率输注肝素，以溶解血栓并改善症状。一名 former 卡车司机出现疼痛加重，随后左示指和中指指尖出现明显发绀及早期坏疽改变。他小鱼际隆起处有明显胼胝，并且报告称他的左手不仅是他的“驾驶”手，而且他还用左手拄拐杖行走。最初的血管造影显示仅手腕处尺动脉闭塞，在小鱼际隆起远侧有血管再通。溶栓开始24小时后，重复血管造影显示血栓溶解，尺动脉广泛通畅。他的症状和手指颜色立即改善，几个月内，他的手恢复正常。该患者没有溶栓治疗的临床后遗症。对于疑似小鱼际锤状指综合征的患者，手部急性闭塞性血栓情况下的导管定向溶栓治疗可能提供一种治疗选择。然而，溶栓治疗有发生严重出血并发症的风险。在开始治疗前，需要仔细判断出血风险的可能性。这为开放手术血管重建提供了一种微创替代方案，尤其是在没有潜在可纠正的解剖缺陷如动脉瘤的情况下。
