The use of intra-arterial urokinase in the management of hand ischemia secondary to palmar and digital arterial occlusion.

Impending gangrene of the hand or digits secondary to palmar or digital artery occlusion can be a devastating complication of upper extremity thromboembolic or atheroembolic disease. Over the past 7 years, 9 patients with severe unilateral hand ischemia and impending tissue loss secondary to distal forearm, palmar arch, and digital artery occlusion were managed with intra-arterial urokinase (UK) infusion. The etiology of the ischemia was thromboembolism in 3 patients, atheroembolism in 2, and traumatic ulnar artery occlusion ("hypothenar hammer syndrome") in the remaining 4 patients. Initial high-dose UK was administered in 3 patients (240,000 U per hour for 2 hours) and all 9 patients were maintained on 80,000 to 120,000 U per hour until clot lysis occurred or until a minimum dose of 600,000 U had been given without clinical improvement. Following UK therapy, the 3 patients with thromboemboli had angiographic demonstration of clot lysis as well as complete resolution of ischemia. The 2 patients with atheroemboli showed no angiographic or clinical improvement, and both required surgical intervention. Angiographic improvement was demonstrated in only 1 patient with traumatic ulnar artery occlusion, although 3 of the 4 patients were clinically improved. A pericatheter thrombosis due to insufficient heparinization and a subcutaneous abscess at the femoral artery puncture site were the only complications of UK infusion. No hemorrhagic complications occurred and no adverse effects of lytic therapy were documented in patients who subsequently required surgery. UK is an effective treatment for recent thromboembolism, because it lyses unorganized thrombi. It is ineffective for treatment of organized thrombi or atheroemboli. Because the etiology of acute hand ischemia is not always obvious at the time of presentation, a trial of UK infusion is warranted, because it is relatively safe and its use may obviate the need for complex microsurgical reconstruction.