Percutaneous Transluminal Angioplasty for Treatment of Critical Hand Ischemia

62-year-old man with insulin-dependent type II diabetes mellitus and chronic renal failure being treated with dialysis complained of chronic critical ischemia of the left hand with severe pain. A necrotic skin lesion with soft tissue infection and osteomyelitis of the distal part of the fourth finger was present (Figure 1A). A standard x-ray of the hand showed diffuse calcifications of the arteries (Figure 1B and 1C). An angiographic study was performed before therapeutic decisions were made. Homolateral antegrade brachial ap- proach with an 11-cm 4F introducer sheath was used. No brachial lesions were present; the ulnar artery was function- ally occluded in the distal part, whereas a series of critical stenoses of the radial artery associated with diffuse disease of the vessels of the hand was documented (Figure 1D). A percutaneous transluminal approach was attempted. Hand amputation was considered the ultimate therapeutic option. After the intra arterial administration of 100 mg of lidocaine (for a better pain control), a 0.014-inch soft coronary guide wire was gently advanced through the radial artery until the deep palmar arch was reached. By using a 2.5- to 80-mm peripheral balloon (Amphirion Deep, Invatec Inc, Brescia, Italy), the lesions were dilated at high pressure (15 bar) (Figure 2A). A good final angiographic result was obtained with immediate pain relief (Figure 2B). The patient was discharged the day after the procedure and 1 week later he underwent a planned surgical operation to remove the in- fected lesion of the finger by amputation. At an 8-month follow-up, the patient was asymptomatic and the surgical wound completely healed (Figure 2C). In conclusion, in selected cases, a percutaneous translumi- nal approach could be considered an effective option for the treatment of critical hand ischemia. A successful procedure can avoid a major amputation.