Colen David L, Ben-Amotz Oded, Stephanie Thibaudeau, Serebrakian Arman, Carney Martin J, Gerety Patrick A, Levin L Scott
Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Philadelphia, PA, USA.
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
J Hand Surg Asian Pac Vol. 2019 Sep;24(3):359-370. doi: 10.1142/S2424835519500462.
Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique. A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations. The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation. When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.
慢性手部缺血是指诸如不耐寒、静息痛、溃疡、组织坏死和手指缺失等进行性非急性缺血症状，在治疗方面构成重大挑战。保守治疗首先是进行医学优化和药物治疗，但当症状持续存在时，可能需要手术干预。存在多种改善血液循环的手术，包括交感神经切除术、动脉搭桥术或静脉动脉化术。本研究的目的是系统回顾已发表的治疗结果，并介绍我们在每种手术技术方面的经验。使用PRISMA指南对1990年至2016年间发表的关于慢性手部缺血手术治疗的文献进行了系统回顾。然后对2010年至2016年间慢性手部缺血的手术干预进行了回顾性研究。主要结果包括疼痛改善、伤口愈合以及新溃疡的发生情况。该综述纳入了38项研究，结果表明所有这三种技术在治疗慢性手部缺血方面均有效。交感神经切除术新溃疡发生率最低（0.8%）；搭桥术现有溃疡愈合率最高（89%）。动脉化术与持续的疼痛改善相关（100%），但并发症更多（30.8%）。我们的系列研究包括18例患者的21只患手，进行了18次交感神经切除术、6次尺动脉搭桥术和1次动脉化术。大多数患手的伤口（89.5%）和疼痛（78.9%）得到改善。没有患者出现新的溃疡，但有1例需要二次截肢。当保守措施无法改善慢性手部缺血时，手术干预是一种有效的最后治疗手段。一种算法方法可以为慢性手部缺血患者确定最佳手术方式。
