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Upper Extremity Critical Limb Ischemia (UE-CLI) can be devastating and may result in amputation. Distal vessel calcification has been shown to be a major factor in causing hand ischemia. Atherectomy in the upper extremities is not typically considered due to the small anatomy; however, the Peripheral Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc.) can access treatment areas with a reference vessel diameter of 1.5mm.
A retrospective, observational, single center (Merit Health Center, Jackson, MS) analysis of 12 patients with calcific disease of the radial artery and UE-CLI was completed to ascertain a treatment algorithm using orbital atherectomy. Demographics, wound healing, and outcomes were assessed.
All patients had good flow to the hand after intervention and none experienced complications during or immediately post-procedure (Figure). The patients have not returned for repeat procedures on the lesions presented here. This retrospective analysis revealed the following important elements for a treatment algorithm using the OAS for UE-CLI: 1. Make sure ACT is therapeutic (∼250 seconds); 2. Use very gentle wire manipulation; 3. Utilize a small OAS crown (1.25 mm); 4. Be aggressive with vasodilators and give it through the exchange catheters; 5. Balloon size for angioplasty should match the size of the vessel. Complete long and low pressure inflations. If a small area does not respond, use a smaller balloon with higher atmosphere inflation pressure.
Upper Extremity Critical Limb Ischemia (UE-CLI) can be treated with endovascular techniques. Obtaining good outflow to the fingers is critical for wound healing and preventing amputation. Orbital atherectomy is a useful tool in preparing vessels for balloon angioplasty; particularly in cases where calcification is present.