title: Upper extremity bypass grafting for limb salvage in end-stage renal failure.
abstract: OBJECTIVE
  Patients with end-stage renal failure and upper-extremity arterial occlusive disease sometimes have painful digital ulceration. We evaluated the efficacy of distal bypass grafting from the brachial artery for limb salvage in this setting.
  
  
  METHODS
  All patients with end-stage renal disease with painful digital ulceration or gangrene of the hand seen from 1992 to 2002 were evaluated with clinical examination and noninvasive studies. Those with evidence of occlusive disease underwent conventional angiography. Individuals with forearm occlusive disease underwent bypass grafting, from the brachial artery to either the distal radial artery or ulnar artery at the level of the wrist or proximal hand. Follow-up was scheduled at regular intervals, and included duplex scanning. Limb salvage and bypass graft patency were determined with life table analysis.
  
  
  RESULTS
  Over 10 years, 18 forearm bypass procedures were performed in 15 patients. The outflow artery was the radial artery in 15 procedures and the ulnar artery in 3 procedures. Bypass conduit was autogenous in all patients. No patient had a functioning arteriovenous fistula at bypass grafting; six limbs had previously occluded fistulas. Two bypass grafts (11%) occluded in the early postoperative period, with resultant progression of gangrene. In the remaining 16 grafts patency was maintained (mean follow-up, 18 months), with pain control and tissue healing.
  
  
  CONCLUSIONS
  Treatment in patients with renal failure with upper extremity occlusive disease may be facilitated with brachiodistal bypass grafting. Pain control and reversal of progression of hand necrosis can be achieved.
authors.affiliation: Institute for Vascular Health and Disease, Albany Medical College, 47 New Scotland Avenue, Albany, NY 12208, USA.
authors.forename: Benjamin B
authors.initials: BB
authors.lastname: Chang
authors.forename: Sean P
authors.initials: SP
authors.lastname: Roddy
authors.forename: R Clement
authors.initials: RC
authors.lastname: Darling
authors.forename: Dale
authors.initials: D
authors.lastname: Maharaj
authors.forename: Philip S K
authors.initials: PS
authors.lastname: Paty
authors.forename: Paul B
authors.initials: PB
authors.lastname: Kreienberg
authors.forename: Kathleen J
authors.initials: KJ
authors.lastname: Ozsvath
authors.forename: Manish
authors.initials: M
authors.lastname: Mehta
authors.forename: Dhiraj M
authors.initials: DM
authors.lastname: Shah
mesh_terms: D000328:Adult; D000368:Aged; D001157:Arterial Occlusive Diseases / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D001916:Brachial Artery / Q000601:surgery*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000401:mortality; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008875:Middle Aged; D017534:Radial Artery / Q000601:surgery*; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D017535:Ulnar Artery / Q000601:surgery*; D034941:Upper Extremity / Q000098:blood supply / Q000601:surgery