Upper extremity bypass is a rare surgery performed in cases of chronic ischemia affecting the hand, forearm, or arm. Interventions for critical ischemia can include bypass, sympathectomy, endarterectomy with patch angioplasty, venous arterialization, or amputation1. Ultimately, bypass can lead to significant improvements in ischemia symptoms2. We present a unique case of right upper extremity revascularization using a lesser saphenous vein graft to connect the radial recurrent artery to deep palmar arch for ischemia and ulceration.

CASE INFORMATION:  A 46-year-old, left-hand-dominant woman with a history of end stage renal disease, two renal transplants, and chronic DVT of the right lower extremity managed with apixaban presented with worsening right-hand pain and ulceration of the small finger. She was previously evaluated by vascular surgery, who recommended cilostazol and nitroglycerin without improvement of her symptoms. Digital pressures showed critical insufficiency with dampened or flat-lined waveforms in each digit. Arterial duplex showed bilateral upper extremity small vessel disease. Angiogram showed radial/ulnar artery occlusion at the level of the forearm and perfusion of the deep palmar arch via anterior interosseous artery.

DISCUSSION/CLINICAL FINDINGS:  The patient underwent a right upper extremity bypass in which the right radial recurrent artery was anastomosed to the deep palmar arch using the reversed contralateral lesser saphenous vein graft tunneled superficial to the carpal tunnel. Intraoperatively, the ulnar artery was thrombosed, and both the ulnar and radial artery were heavily calcified as evidenced by the angiogram. The radial recurrent artery was found to have the least calcifications, and an end-to-end anastomosis was performed using 9-0 nylon sutures. The superficial palmar arch was incomplete. The deep palmar arch was chosen as the outflow vessel through an end-to-side anastomosis using 9-0 nylon sutures. Postoperatively, she was kept on a therapeutic heparin drip, and biphasic signals were visualized on Doppler up to the metacarpophalangeal joint of the volar thumb and the PIP joints of all the fingers, followed by outpatient apixaban. In the two months following the procedure, the patient was found to have significant improvement in the ulceration of her small finger.