THE USE OF INTRAARTERIAL UROKINASE IN THE MANAGEMENT OF HAND ISCHEMIASECONDARY TO PALMAR AND DIGITAL ARTERIAL-OCCLUSION

Impending gangrene of the hand or digits secondary to palmar or digita l artery occlusion can be a devastating complication of upper extremit y thromboembolic or atheroembolic disease. Over the past 7 years, 9 pa tients 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 etiolog y 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 wer e 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 h ad angiographic demonstration of clot lysis as well as complete resolu tion of ischemia. The 2 patients with atheroemboli showed no angiograp hic or clinical improvement, and both required surgical intervention. Angiographic improvement was demonstrated in only I patient with traum atic ulnar artery occlusion, although 3 of the 4 patients were clinica lly improved. A pericatheter thrombosis due to insufficient hepariniza tion and a subcutaneous abscess at the femoral artery puncture site we re the only complications of UK infusion. No hemorrhagic complications occurred and no adverse effects of lytic therapy were documented in p atients who subsequently required surgery, UK is an effective treatmen t for recent thromboembolism, because it lyses unorganized thrombi. it is ineffective for treatment of organized thrombi or atheroemboli. Be cause 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 micro surgical reconstruction.