A systematic approach to severe hand ischemia.

Because severely symptomatic hand ischemia is not common and because there are a wide variety of clinical conditions which can cause arterial insufficiency of the upper extremity, a retrospective study has been done to determine the efficacy of various diagnostic manipulations used in managing 65 patients with severe hand ischemia at the Northwestern University McGaw Medical Center, Traumatic, thermal, and iatrogenic causes of hand ischemia were diagnosed by simple history taking, as was advanced uremic arteritis. Doppler ultrasound and digital arterial pressure recording were confirmative, rather than diagnostic. These aided in defining precise degrees of ischemia and identifying proximal arterial occlusions. Invasive total extremity angiography clarified atherosclerotic, atheroembolic, and other chronic occlusive lesions while serum electrophoresis and immunoelectrophoresis defined the polyclonal and monoclonal gammopathies. When digital necrosis was present, organic arterial occlusions usually were found. These responded best to direct arterial reconstruction down to the mid-palm level. Transpleural, transthoracic sympathectomy was useful as an adjuvant or as definitive treatment for distal digital arterial occlusions. Selective vasodilator therapy was used as dictated by the cause of ischemia and its eventual outcome.