Revision periarterial sympathectomy for recurrent digital ischaemia: a report with 11 patients

Following periarterial sympathectomy, patients with recurrent digital ischemia due to vasospastic or vaso-occlusive disease have few remaining treatment options. We performed a retrospective review from 1997 to 2019 to determine the safety and efficacy of revision periarterial sympathectomy. Eleven patients were identified who underwent revision periarterial sympathectomy, performed on average 84 months after their initial procedure. Preoperatively, all patients had worsening ischemic pain and five had non-healing digital ulcers. Revision digital periarterial sympathectomy alone was performed in seven patients, while four had a more extensive sympathectomy. Mean follow-up after revision was 23 months (range 3 to 76). Eight patients had symptomatic improvement and four healed their digital ulcers. Three patients developed new ulcers during follow-up, of which two healed with conservative management and one required three digital amputations. Revision periarterial sympathectomy is effective in providing symptomatic improvement and digital ulcer healing with minimal postoperative complications. Level of evidence: IV

Accidental adrenaline auto-injector-induced digital ischaemia: a proposed treatment algorithm

Increased numbers of adrenaline auto-injectors (AAIs) are in circulation in the UK. The rate of accidental auto-injection injuries has increased during this time. Various treatment strategies are described in the literature. We present the case of a 32-year-old, right-hand-dominant man who sustained an unintentional AAI injury to the volar aspect of his right thumb. On presentation to the emergency department, the thumb was ischaemic. There was no improvement with simple conservative measures (warm soaks). The patient was referred to our tertiary hand surgery service and a digital block using 2% lidocaine promoted reversal of ischaemia within 2 hours with no long-term sequelae. Phentolamine rescue, on standby, was not necessary in this case. In this case report, we highlight the therapeutic challenges associated with managing AAI injury and propose an evidence-based treatment algorithm to prevent risk of severe adverse outcomes such as digital necrosis.

Digital Ischaemia following Radial Arterial Cannulation

Indwelling arterial catheters are used routinely for continuous haemodynamic monitoring during major surgery and in critically ill patients. Major complications are rare. We describe two cases of patients in which arterial catheterisation was associated with acute radial arterial thrombosis and radial ischaemic neuropathy. Timely recognition was paramount to successful management.

Systemic sclerosis skin is a primed microenvironment for soft tissue calcification—a hypothesis

Calcinosis cutis, defined as sub-epidermal deposition of calcium salts, is a major clinical problem in patients with SSc, affecting 20–40% of patients. A number of recognized factors associated with calcinosis have been identified, including disease duration, digital ischaemia and acro-osteolysis. Yet, to date, the pathogenesis of SSc-related calcinosis remains unknown, and currently there is no effective disease-modifying pharmacotherapy. Following onset of SSc, there are marked changes in the extracellular matrix (ECM) of the skin, notably a breakdown in the microfibrillar network and accumulation of type I collagen. Our hypothesis is that these pathological changes reflect a changing cellular phenotype and result in a primed microenvironment for soft tissue calcification, with SSc fibroblasts adopting a pro-osteogenic profile, and specific driving forces promoting tissue mineralization. Considering the role of the ECM in disease progression may help elucidate the mechanism(s) behind SSc-related calcinosis and inform the development of future therapeutic interventions.

Paraneoplastic acral vascular syndrome: case presentation and literature review

A 65-year-old man, a smoker, presented to the emergency department with progressive digital ischaemia, fever and weight loss. The clinical examination revealed generalised lymphadenopathy and ischaemic changes of the right distal phalanges of the second, third and fourth fingers. He had an ultrasound-guided biopsy of the cervical lymph node, which showed histopathological findings of classic Hodgkin’s lymphoma. Paraneoplastic acral vascular syndrome (PAVS) is a rare phenomenon and seen more in solid malignancies. There are very few reported cases of PAVS in haematological malignancies, including Hodgkin’s lymphoma. This case highlights the idea that the presence of acral vascular syndrome—especially in older patients—should alert physicians to search for an underlying malignancy as part of the medical evaluation. Also, it shows that medical treatment may slow the progress of the digital ischaemia until the culprit tumour has been identified and treated.

Digital ischaemia of the upper limbs in middle age: consider arterial thoracic outlet syndrome until proven otherwise !

Objectives Patients presenting with digital upper limb ischaemia are occasionally referred to rheumatology services to rule out vasculitis. We present two cases of delayed diagnosis of arterial thoracic outlet syndrome (TOS) in middle aged patients presenting with digital ischaemia in order to raise awareness of this important pathology that requires timely surgical intervention. Methods Two cases of progressive ischemia of the right upper extremity caused by primarily undiagnosed compression of the subclavian artery (SCA) by an accessory cervical rib are presented. Both patients case notes, radiological images, intra-operative and postoperative findings were reviewed. Patients were followed up after at least 6 months to assess prognosis. Results Both patients had working diagnosis of Buerger’s disease and treated with prostaglandin infusions prior to establishment of the diagnosis of arterial thoracic outlet syndrome. Both patients were heavy smokers and one patient had bilateral symptoms and history of axial spondyloarthropathy and positive HLA-B27. Surgical thrombectomy of the upper limb arteries along with resection of a cervical rib and repair of the SCA with interposition graft were necessitated to successfully heal digital ulcers in one patient. However, late presentation in the second patient led to the loss of three fingers and the need of plastic reconstructive surgery following cervical rib resection and revascularisation. Conclusion High index of suspicion of arterial TOS should be maintained in middle aged patients presenting with digital or upper limb ischaemia even in presence bilateral symptoms or relevant risk factors of other diagnoses such as smoking or positive rheumatological history.