Thrombolytic therapy of distal upper extremity occlusion(hypothenar hammer syndrome)

A therapeutic option of a rare disease

Franz Hafner

Medical University of Graz

Division of Angiology

Disclosure

Speaker name:

Franz Hafner

I do not have any potential conflict of interest

Clinical presentation of upperextremity occlusion

• Pallor

• Nekrosis

• Gangrene

Reason Example

Atherosclerosis and embolism PAOD, atrial fibrillation

Auto-immune disease Scleroderma and other collagenoses,

vasculitis, rheumatoid arthritis

Myeloproliferative disorders Thrombocytosis (ETH), polycythemia (PVR),

leukemia

Hypercoagulability Sepsis, DIC, Antiphospholipid antibody

syndrome

Traumatic Hypothenar Hammer Syndrom

Iatrogene Arterial punction and injection

Others frostbite, cytotoxic medication

Etiology of hand-ischemia

Hypothenar hammer syndrome

• Damage to distal part of ulnar artery– Acute or repetitive trauma

• Usually unilateral• Aneurysm or occlusion of ulnar

artery• Plus digital artery occlusions in the

supply area of ulnar artery (not all digits affected)

• Smoking may predispose tothrombotic complications, hyperviscosity and endothelialdysfunction

Risk factors for HHSn

OR

Scharnbacher et al. Am. J. Ind. Med. 2013

Yuen JC. Ann Plast Surg 2011

The vulnerable point of ulnar artery

Natural course of HHS

• Raynaud phenomenon 35-100%

• Digital ischemia 45-68%

• Digital necrosis 37-43%

• Dominant hand 92%

• Recurrence rate >30%

Marie I. et al. Medicine 2007;86;6

Thrombolysisa therapeutic option?

De Martino et al. Hand Clin 2015

Data of CD-fibrinolysis in HHS

• Small case series (34 cases since 1986)• Access site: 60% brachial, 40% femoral• Agent: 53% rtPA, 44% urokinase, 3% streptokinase• Heparine: 95%

• Success rate:– 70% angiographic improvement (22% ulnar, 70% digital

arteries)– 82% clinical improvement

• Best results in cases with small delay (>2 weeks worsesuccess rate)

Complications

• Variable complication rate– Between 0 and 75% (pooled complication rate 18%)

• bleeding (8%)– Access site

– Rare systemic bleeding complications

• Thrombotic complications– Catheter-associated thrombosis

– embolism

• Pseudoaneurysma at access site, swelling, pain

Case – Hypothenar Hammer Syndrome

42 year old male construction worker

Pain and pallor digit 2-4 left hand

Smoker (20py)

Delay 14 days

„our regimen of CDT in HHS“

• 4F brachial access, US-guided puncture

• Microcatheter (Rebar® 27) distal ulnar artery

• Heparine 1000 IE/h via introducer sheath(APTT adjusted, 60-80sec)

• rtPA (Actilyse ®) 1.5mg/h via microcatheter

• Alprostadil 0.4µg/h via introducer sheath

• Duration of CDT: max 24 hours

Baseline

Baseline

Ulnar aneurysm

Digital occlusion

Classic findings in HHS

Angio after 24h CDT

Angio after 24h CDT

Angio after 24h CDT

Summary

– Catheter-directed thrombolysis represents a beneficial therapy in hypothenar hammersyndrome

– Best results in cases with small delay of symptoms

– Brachial access preferred

– Improvment of digital perfusion and symptomsdespite frequent persisting ulnar occlusion

Thrombolytic therapy of distal upper extremity occlusion(hypothenar hammer syndrome)

A therapeutic option of a rare disease

Franz Hafner

Medical University of Graz

Division of Angiology