Arterial Thrombosis

fingers (Fig. 24—6A). The mass occupied the entire space between the two arteries and a 1-cm segment of the superficial arch appeared thin-walled and fibrotic at the origin of the pseudoaneurysm (Fig. 24—6B). Proximal and distal control of the vessel was obtained with a vascular loop around the superficial arch at the base of the common digital arteries. Resection of the pseudoaneurysm was done, and then the free ends of the arch were brought together easily (Fig. 24—6C). A primary anastomosis in this position was formed by an intersection with the superficial palmar arch and the third and fourth common digital arteries. If there is concern that the tension produced by such an anastomosis could lead to occlusion, then a timed Allen test should be performed. This test can be performed by closing the cut ends of the superficial palmar arch with microvascular clamps. Vessel loops provided occlusion of the arch on both sides proximal to the common digital arteries. Normal color and turgor was noted with brisk capillary refill in the ring and little fingers within 3 seconds after release of either the ulnar or the radial side of the superficial palmar arch. If the arteriogram shows digital flow and the Allen test has demonstrated sufficient flow at rest, you will not need to perform a vein graft, and the superficial palmar arch can be ligated (Fig. 24—7). A timed Allen test was again performed, with occlusion of the radial and ulnar arteries at the wrist crease. Brisk capillary refill was again noted within 3 seconds after sequential release of the occlusion of the arch.

A patient-oriented approach is always necessary, and patient selection is important because the patient must be willing to play an active, cooperative role in the perioperative period.

Postoperatively, extensive rehabilitation is seldom necessary after vein grafting in ulnar artery thrombosis, and the hand is placed in a bulky compressive dressing

Ulnar Artery Thrombosis
Figure 24—7. End-to-side and end-to-end anastomoses as a technique used to regain blood flow when necessary.

with dorsal splints. This dressing allows the fingers freedom to move and active range of motion. Supervised occupational hand therapy is added if the patient has difficulty with range of motion. A soft dressing is left in place for 2 weeks, at which time the sutures are removed. The foot is dressed with a compressive dressing, which is removed at 5 days. A support stocking is recommended for 6 to 8 weeks, and if the main portion of the saphenous vein has been harvested, the patient is advised that there will be some swelling of the foot, which will diminish over time. At the time of discharge, the patient is instructed on appropriate anticoagulation therapy, and at 2 weeks, if the wounds are healing, the patient is allowed increased use of the hand, but is not allowed to return to unrestricted activities for 6 to 8 weeks. Specific strengthening exercises are given only if the patient has pain or stiffness.

Alternative Methods of Management

Concerns with vein graft harvesting include selecting a vein graft that is too small along with iatrogenic damage of the graft during dissection. The length of the graft is crucial, as is meticulous dissection to avoid saphenous or other sensory nerve damage. Hemostasis at the branches is important as well as sustaining that hemostasis

Figure 24—8. The graft and surgical technique in arteries that do not match completely secondary to size.

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