ARTERIOVENOUS REVERSAL FOR LIMB SALVAGE IN UNRECONSTRUCTIBLE UPPER EXTREMITY ARTERIAL OCCLUSIVE DISEASE

Purpose: Peripheral vascular disease of the upper extremity as a resul t of atherosclerotic disease or systemic vascular disorders presents a difficult management problem to the vascular surgeon. When extensive distal disease is present bypass procedures with standard arterial rec onstruction techniques may not be possible. The use of retrograde perf usion to deliver oxygenated blood to the capillary bed by means of a n ormal venous system is not new. Flow reversal has been attempted in th e myocardial, cerebral, and distal extremity circulations. Arterioveno us reversal (AVR) has been described for limb salvage in patients with upper extremity ischemia, with variable results. Methods: We performe d six AVR procedures on five patients with diffuse distal arterial dis ease and limb-threatening upper extremity ischemia. Two patients had i nsulin-dependent diabetes, one had systemic lupus erythematosus (two e xtremities), one had rheumatoid arthritis with vasculitis, and the rem aining patient had CRST (calcinosis, Raynaud's disease, sclerodactyly, telangiectasia) syndrome. The two patients with diabetes had systemic manifestations of atherosclcrotic vascular disease and lower extremit y ischemia; the remaining three patients had no evidence of atheroscle rosis. In all patients the AVR was performed at the most distal site o f nondiseased artery. Results: Limb salvage was obtained in all cases; one patient had a healed minor digital amputation, and another patien t had a healed major amputation. Clinical improvement with resolution of pain was achieved in five of six cases. The remaining patient had a significant diabetic neuropathy that was believed to contribute to he r persistent pain. Conclusions: In patients with severe upper extremit y ischemia not amenable to standard revascularization techniques, AVR should be considered to provide limb salvage and maximize hand functio n.