Clinical Example: Segmental ulnar artery excision and repair for aneurism with emboli

Arterial insufficiency of the fingers may be due to a variety of problems, including vasospastic problems such as Raynaud disease, partial or complete local blockage, or blood clots traveling downstream from the heart or large arteries.

The ulnar artery in the palm is prone to injury because it runs through the heel of the palm, an area which people lean on, push with, and hit (hypothenar hammer syndrome). An injured artery may form an aneurism containing blood clots which can break off, running downstream into the fingers, where they block blood flow and trigger blood vessel spasm.

This is an example of such a situation, treated by removing the damaged arterial segment and repairing the ends to restore flow and prevent further emboli.
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This 42 year old man was evaluated for episodes of cold, painful fingers over the last two weeks. Examination showed splinter hemorrhages, which look like splinters in the nailbed, but are actually the effects of tiny blood clots, usually breaking off from a larger upstream blood clot.
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An arteriogram demonstrated partial blockage of the ulnar artery in the palm consistent with a partially occluded ulnar artery aneurism.
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It also showed segmental digital artery occlusion suggestive of tiny emboli in the middle, ring and small fingers.
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In preparation for vascular graft reconstruction, possible forearm donor veins were marked prior to tourniquet inflation. Veins branching in a distal direction were chosen in the event that a "Y" shaped graft was needed. Pisiform, hamate and ulnar artery course are marked as well as the surgical incisions.
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The aneurism with intraluminal clot is seen as brownish coloration of the vessel wall.
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Prior to excision, the elasticity of the ulnar artery and the possibility of end to end repair was tested.
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The artery appeared sufficiently elastic to allow repair without graft.
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Diseased segment excised.
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Intraluminal thrombus.
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Urokinase was injected intraarterially into the distal segment to promote thrombolysis of digital emboli during the vascular repair.
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Repair.
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After touniquet deflation.
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The patient had an uneventful recovery and no further vasospastic episodes.


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Ulnar Artery Aneurism
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