Arteriovenous reversal for limb salvage in unreconstructible upper extremity arterial occlusive disease

Peripheral vascular disease of the upper extremity as a result 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 reconstruction techniques may not be possible. The use of retrograde perfusion to deliver oxygenated blood to the capillary bed by means of a normal venous system is not new. Flow reversal has been attempted in the myocardial, cerebral, and distal extremity circulations. Arteriovenous reversal (AVR) has been described for limb salvage in patients with upper extremity ischemia, with variable results.

We performed six AVR procedures on five patients with diffuse distal arterial disease and limb-threatening upper extremity ischemia. Two patients had insulin-dependent diabetes, one had systemic lupus erythematosus (two extremities), one had rheumatoid arthritis with vasculitis, and the remaining patient had CRST (calcinosis, Raynaud's disease, sclerodactyly, telangiectasia) syndrome. The two patients with diabetes had systemic manifestations of atherosclerotic vascular disease and lower extremity ischemia; the remaining three patients had no evidence of atherosclerosis. In all patients the AVR was performed at the most distal site of nondiseased artery.

Limb salvage was obtained in all cases; one patient had a healed minor digital amputation, and another patient 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 her persistent pain.

In patients with severe upper extremity ischemia not amenable to standard revascularization techniques, AVR should be considered to provide limb salvage and maximize hand function.