Management of acute hand ischemia^*

CREST: calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia; CT: computed tomography; HAIDI: hemodialysis access-induced distal ischemia; MCTD: mixed connective tissue disease; SLE: systemic lupus erythematosus.

* Acute ischemia is defined as a rapidly developing or sudden decrease in perfusion (<2 weeks onset), usually producing new or worsening (ie, acute-on-chronic) symptoms or signs.

¶ Systemic anticoagulation helps minimize the propagation of any thrombus. The choice of agent and route of administration depends on the treatment setting (inpatient, outpatient).

Δ Wound care consists of debridement and dressings appropriate for the character of the wound. Stable, dry gangrene can be managed with dry dressings. Revascularization, when indicated, is performed prior to consideration of amputation. For tissue loss, await demarcation before amputation.

◊ Vascular assessment includes evaluation of upper extremity pulses, auscultation for bruits, bilateral upper extremity blood pressure measurements, Allen test, and vascular imaging (eg, duplex ultrasound, CT angiography, possibly arteriography). Vascular imaging determines the presence of structural vascular disease, its location, and its extent.

§ Structural vascular disease-causing luminal obstruction is distinguished from physiologic disease (ie, vasoconstriction), which can be related to medication effects or spontaneous (ie, Raynaud phenomenon). Structural vascular obstruction can affect the proximal vasculature (subclavian, brachial radial, ulnar), distal vasculature (deep or superficial palmar arch, digital vessels), or both.

¥ For HAIDI, refer to UpToDate topics discussing additional potential treatments.

‡ Proximal aneurysmal disease typically involves the subclavian artery. The axillary artery (eg, crutch syndrome) or other proximal vessels can be affected. Distal aneurysm typically affects the ulnar artery (ie, hypothenar hammer syndrome).

† Prevention of future ischemic events may include ongoing antithrombotic therapy (eg, atrial fibrillation), risk reduction strategies for atherosclerotic disease (eg, antiplatelet therapy, statin therapy), treatment of any embolic source (eg, cardiac valve repair, repair/exclusion of aneurysm), or treatment of arterial compression/entrapment (eg, first rib resection), if not already done. Refer to UpToDate topics discussing specific etiologies.

** Smoking cessation is recommended for all patients, but for patients with Buerger disease, it is of particular importance for limiting disease progression.