title: Anatomic findings and outcomes associated with upper extremity arteriography and selective thrombolysis for acute finger ischemia.
abstract: OBJECTIVE
  Limited evidence exists to guide clinical management of acute finger ischemia (AFI). To further inform diagnostic evaluation and decision making, we evaluated anatomic findings, procedural management, and amputation-free survival in an institutional cohort of patients with AFI.
  
  
  METHODS
  Consecutive patients undergoing transfemoral upper extremity angiography for AFI were identified. Clinical, laboratory, and procedural data were collected retrospectively from medical records, and arteriograms were reviewed to characterize anatomic findings. Telephone interviews were used to determine long-term outcomes, and additional symptomatic assessments (Symptom Severity and Functional Status scale, the Cold Sensitivity Severity scale, and the McGill Pain Severity Scale) were available in a subgroup of patients. Outcomes included anatomic findings, use of thrombolysis, complications, and amputation-free survival. Descriptive statistics and survival analysis were used to evaluate results.
  
  
  RESULTS
  Thirty-five patients (54% women) were analyzed with a median follow-up of 13.7 months. Symptom duration at time of presentation ranged from 1 to 28 days, and seven patients had tissue loss or gangrene, or both. Mean age was 47.7 ± 12.2 years. Baseline characteristics included smoking in 22 (65%), connective tissue disorder in 11 (31%), and history of repetitive hand trauma in 10 (29%). The most frequent anatomic location of arterial pathology identified during angiography was distal to the wrist (n = 32), including eight ulnar/radial aneurysms; upper arm (n = 3) and forearm (n = 8) lesions were less common. Sixteen patients were treated with catheter-directed thrombolysis, of which eight (50%) had interval anatomic improvement on repeat angiography. Procedure-related adverse events associated with angiography included bleeding (n = 3) and pseudoaneurysm (n = 1). Eleven of 35 patients had subsequent surgical revascularization at a median of 15 days after angiography. Estimated (standard error) amputation-free survival was 0.88 (0.07) at 1 month and 0.84 (0.08) at 6 months among patients without tissue loss or gangrene. Estimated 60-day amputation-free survival was 0.84 (standard error, 0.08). Overall amputation-free survival was similar between patients managed with vs without thrombolysis (P = .61), but subgroup analysis of those patients without tissue loss or gangrene at the time of presentation revealed a trend toward improved amputation-free survival with use of thrombolysis, with 60-day amputation-free survival of 0.92 vs 0.75 (P = .12). Persistent late symptoms were present in 17 patients (48.6%) at the last follow-up and were generally characterized as mild by functional and pain scale assessments.
  
  
  CONCLUSIONS
  Angiography performed for AFI frequently identifies distal occlusive disease, and catheter-directed thrombolysis may expand revascularization options in select patients.
authors.affiliation: Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Arsalla
authors.initials: A
authors.lastname: Islam
authors.affiliation: Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Colston
authors.initials: C
authors.lastname: Edgerton
authors.affiliation: Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Jeanette M
authors.initials: JM
authors.lastname: Stafford
authors.affiliation: Department of Orthopedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Andrew
authors.initials: A
authors.lastname: Koman
authors.affiliation: Department of Orthopedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Zhongyu
authors.initials: Z
authors.lastname: Li
authors.affiliation: Department of Orthopedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Beth P
authors.initials: BP
authors.lastname: Smith
authors.affiliation: Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Edwards
authors.affiliation: Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC. Electronic address: macorrie@wakehealth.edu.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Corriere
mesh_terms: D000208:Acute Disease; D000328:Adult; D000671:Amputation, Surgical; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging* / Q000188:drug therapy* / Q000401:mortality; D003661:Decision Support Techniques; D018572:Disease-Free Survival; D005260:Female; D005385:Fingers / Q000098:blood supply*; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging* / Q000188:drug therapy* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D011237:Predictive Value of Tests; D011859:Radiography; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome