Treatment of Critical Hand Ischemia via Orbital Atherectomy and Balloon Angioplasty in an African-American Hemodialysis Patient

Compared to critical limb ischemia (CLI), there is a dearth of published literature on critical hand ischemia (CHI), despite the similar high risk of amputation. CHI can be caused by acute vascular injury, chronic vasospastic disease, or occlusive arterial disease of the above- or below-the-elbow (BTE) arteries.¹ Diabetics and/or patients with end-stage renal disease (ESRD) on hemodialysis are at higher risk of severe BTE artery disease, especially radial artery calcification.^2–5

Calcified lesions are challenging to treat, as they are difficult to completely dilate and prone to dissection during balloon angioplasty.^6–8 In a few case reports, balloon angioplasty was used successfully to treat occluded or calcified radial arteries^9–11; however, preparation of complex calcified lesions before balloon angioplasty with atherectomy should be the first-line therapy, as it has been shown in CLI studies that it makes the balloon delivery easier and outcomes are improved.^8,12 Atherectomy devices in the upper extremity arteries are not commonly used due to the small vessel size. The Diamondback 360° Peripheral Orbital Atherectomy System (Cardiovascular Systems, Inc. [CSI]) is an atherectomy device that can access treatment areas with a reference vessel diameter of <2.0 mm.¹³

In this report, we present the case of an African-American hemodialysis patient with CHI due to a calcified radial artery who was treated with orbital atherectomy and balloon angioplasty, and underwent follow-up at six weeks post procedure.

Case Report

A 69-year-old African-American gentleman with a past medical history of hypertension, diabetes mellitus, hyperlipidemia, end-stage renal disease on hemodialysis, and and bilateral above-knee amputation was referred from his dialysis center for resting ischemia to his left hand. He had a dialysis fistula to the left upper arm and developed severe pain, discoloration, and necrotic areas to the tips of his fingers. He was previously admitted to another local hospital for 12 days and treated with anticoagulation with no improvement, then discharged home. His pain progressively worsened and the necrotic areas were increasing in size. The pain was so severe he was unable to move his fingers (Figure 1). He was then referred to our facility at Merit Health Central, in Jackson, Mississippi. Review of the left upper extremity arterial Doppler study showed severe peripheral arterial disease. The diagnostic angiogram revealed severe disease in the proximal and mid left radial artery, with an occluded segment just proximal to the wrist, along with an occluded ulnar artery distally above the wrist (Figure 2). The recommendation was to proceed with endovascular intervention of the left radial artery.

The right groin was prepped and draped in the usual fashion. Lidocaine 1% was used for local anesthesia. A 5 French (Fr) sheath was used to cannulate the right femoral artery.  A 5 Fr Berenstein catheter (Merit Medical) and an Advantage wire (Terumo) were used to advance the catheter into the proximal brachial artery. Selective angiography was then performed. To perform a BTE angiogram, a long NaviCross catheter (Terumo) was advanced over the Advantage wire to the distal brachial artery. A long 6 Fr Destination sheath (Terumo) was advanced to the mid brachial artery. Heparin and tirofiban (Aggrastat) were given intravenously. Using a ChoICE PT guidewire (Boston Scientific) and a Seeker catheter (BD), the occluded segment in the distal radial artery was crossed, then the wire was exchanged to a ViperWire (CSI), after 1 mg of verapamil was given through the Seeker catheter. Orbital atherectomy was performed using 1.25 Solid Crown (CSI) (Figure 3), followed by balloon angioplasty using 2.0 x 40 mm balloon in the distal segment of the radial artery. A 2.5 x 150 mm balloon was utilized in the proximal and mid portion of the vessel. Each balloon was inflated between 4-6 atmospheres for 2-3 minutes (Figure 4). The final angiogram revealed excellent results.

The day after the procedure, the patient was already able to move his fingers without severe pain. Color had returned to his fingertips. He was extremely pleased with the results and was discharged home (Videos 1-2).

The patient returned to the clinic six weeks after the procedure for his follow-up appointment. The ischemic ulcerations had completely healed (Figure 5). His pain had resolved, allowing full mobility of his hand again. Coloration had returned to normal (Figure 5).

Discussion

CHI, although less common than CLI, is a serious condition with a high risk of amputation, especially in patients with diabetes and ESRD.^2,14 Previous studies have shown that diabetes and ESRD are the two most common risk factors of radial artery calcification.⁵ The African-American patient presented herein is a prime example of CHI — the presentation of his severely calcified radial artery and occluded ulnar artery along with his medical history of hypertension and hyperlipidemia is similar to the 11 patients in our previous below-the-elbow (BTE) atherectomy study.¹⁵ In that study, 100% of patients had hypertension, 73% were African-American, and greater than 80% had diabetes and ESRD. Similar to the case herein, all study patients were treated with orbital atherectomy, resulting in good blood flow to the hand after intervention, with no complications during or immediately after the procedure.

In a recently published mini-review¹³, we examined and discussed articles published over the past decade regarding the endovascular treatment of BTE arteries in CHI. We found that the endovascular treatment of BTE arteries is rarely described in the literature, and most are case reports or single-center retrospective studies of less than 40 patients. The main treatment mode in these limited studies was balloon angioplasty (uncoated or drug-coated) with or without stenting. Immediate pain relief, wound healing, and a high rate of technical success were reported in these studies, along with no procedure-related complications. Patients were asymptomatic up to two years in select cases with drug-coated balloons^16,17; however, we argue that severely calcified lesions need to be prepared or modified with atherectomy before balloon angioplasty. As previously stated, balloon angioplasty has limitations, particularly in complex, calcified lesions, that can result in recoil, dissection, and restenosis. For example, in CLI patients, Janas et al¹⁸ found that bailout stenting due to flow-limiting dissection was required more often in the balloon angioplasty group compared to the atherectomy group. More importantly, atherectomy was associated with a lower risk of target lesion revascularization in CLI patients.¹⁸

Similar advantages of atherectomy use for treating severely calcified lesions in CHI patients have also been reported; however, only three single-center studies and three case reports are available regarding the use of atherectomy prior to balloon angioplasty.¹³ We add to this information by reporting the use of orbital atherectomy and balloon angioplasty in an African-American hemodialysis patient for the treatment of a complex, severely calcified radial artery lesion. Excellent angiographic outcomes with no complications resulted in resolution of the patient’s pain with improved mobility and coloration of his fingers. At the 6-week follow-up, the ischemic ulcerations had completely healed.  The utilization of orbital atherectomy and balloon angioplasty in this complex case prevented an amputation.

Conclusion

Current data provides a signal that orbital atherectomy treatment of calcified radial arteries is feasible and safe. Obtaining good outflow to the fingers is critical for wound healing and preventing amputation in complex CHI patients. Randomized trials are warranted to further the knowledge of optimal CHI treatment. 

¹Director of the Interventional Catheterization Laboratory, Chief of Cardiovascular Services of CHS Hospitals in Mississippi, Merit Health Central, Jackson, Mississippi; ²Interventional Cardiology Nurse Practitioner, Merit Health Central, Jackson, Mississippi; ³Sr. Scientific Affairs Associate, Cardiovascular Systems, Inc., St. Paul, Minnesota; ⁴Director of Scientific Affairs, Cardiovascular Systems, Inc., St. Paul, Minnesota

Disclosures: Dr. Bahro reports he is a consultant to Cardiovascular Systems, Inc. Connie Williams reports no conflicts of interest regarding the content herein. Dr. Igyarto and Dr. Martinsen own stock in and are employed by Cardiovascular Systems, Inc.

The authors can be contacted via Abdul Bahro, MD, FACC, FSCAI, at abdul.bahro@mymerithealth.com.

1. Higgins JP, McClinton MA. Vascular insufficiency of the upper extremity. J Hand Surg. 2010 Sept; 35(9): 1545-1553; quiz 1553.
2. Ferraresi R, Palloshi A, Aprigliano G, et al. Angioplasty of below-the-elbow arteries in critical hand ischaemia. Eur J Vasc Endovasc Surg. 2012 Jan; 43(1): 73-80.
3. Bojakowski K, Zawadzki M, Mruk B, et al. Critical hand ischemia after radial access for coronary angiography - case report. Pol J Radiol. 2017; 82: 19-23.
4. Nicolosi AC, Pohl LL, Parsons P, et al. Increased incidence of radial artery calcification in patients with diabetes mellitus. J Surg Res. 2002 Jan; 102(1): 1-5.
5. Janda K, Krzanowski M, Gajda M, et al. Impaired fasting glucose and diabetes as predictors for radial artery calcification in end stage renal disease patients. Int J Endocrinol. 2013; 2013: 969038.
6. Fitzgerald PJ, Ports TA, Yock PG. Contribution of localized calcium deposits to dissection after angioplasty. An observational study using intravascular ultrasound. Circulation. 1992 July; 86(1): 64-70.
7. Cioppa A, Stabile E, Popusoi G, et al. Combined treatment of heavy calcified femoro-popliteal lesions using directional atherectomy and a paclitaxel coated balloon: One-year single centre clinical results. Cardiovasc Revasc Med. 2012 July; 13(4): 219-223.
8. Mustapha JA, Diaz-Sandoval LJ, Karenko B, Saab F. Atherectomy and critical limb ischemia: a treatment approach for severely calcified vessels. Vascular Disease Management. 2013; 10(10): E198-E207.
9. Arabi M, Ahmed I, Qattan N. Transluminal recanalization of chronic total occlusion of radial artery using rendezvous technique: a case report and literature review. J Clin Imaging Sci. 2014; 4: 36.
10. Tasal A, Bacaksiz A, Erdogan E, Goktekin O. Successful angioplasty for radial artery chronic total occlusion in a patient with digital gangrene. Postepy Kardiol Interwencyjnej. 2013; 9(3): 304-306.
11. Ruzsa Z, Pintér L, Kolvenbach R. Anterograde recanalisation of the radial artery followed by transradial angioplasty. Cardiovasc Revasc Med. 2010 December; 11(4): 266.e1-e4.
12. Shammas NW, Lam R, Mustapha J, et al. Comparison of orbital atherectomy plus balloon angioplasty vs. balloon angioplasty alone in patients with critical limb ischemia: results of the CALCIUM 360 randomized pilot trial. J Endovasc Ther. 2012 August; 19(4): 480-488.
13. Bahro A, Igyarto Z, Williams C, Abraham JP, Martinsen BJ. Treatment of critical hand ischemia via orbital atherectomy and focal force balloon angioplasty: A mini-review. Cardiovasc Revasc Med. 2019 Mar; 20(3): 248-253.
14. Annabestani Z, Kassaian SE, Mohajeri-Tehrani MR, et al. Retrograde trans-femoral approach for successful percutaneous angioplasty in a diabetic patient with ischemic hand ulcer: a case report. J Teh Univ Heart Ctr. 2013; 8(4): 205-209.
15. Bahro A, Igyarto Z, Martinsen B. Critical hand ischemia treatment via orbital atherectomy-A single center observational retrospective analysis. Cardiovasc Revasc Med. 2017 March; 18(2): 91-94.
16. Ferraresi R, Fattori SM, Cornacchiari M, Palloshi A. First use of drug-eluting balloon for below-the-elbow artery occlusion in a hemodialysis patient: a 3-year follow-up. J Vasc Access. 2013 June; 14(2): 202-203.
17. El Amrawy AM, Jimenez JL, Camacho SJ, et al. Long term efficacy of drug coated balloon for radial artery angioplasty. Cardiol J. 2018; 25(6): 743-744.
18. Janas A, Buszman PP, Milewski KP, et al. Long-term outcomes after percutaneous lower extremity arterial interventions with atherectomy vs. balloon angioplasty – propensity score-matched registry. Circ J. 2017 Feb; 81(3): 376-382.