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Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique.

Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations.

Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation.

Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Parkes Weber Syndrome (PWS) is a congenital disorder characterized by the presence of arteriovenous malformations (AVMs) in upper or lower extremities. We herein present a 35 year-old male with PWS with complex AVMs in the right upper extremity; he had been previously treated with multiple sessions of vessel embolization, sclerotherapy and AVM resections. The patient presented to our clinic with two month history of progressive hand ischemia, digit necrosis and infection. Angiography was performed demonstrating numerous AVMs and filiform flow through the ulnar artery with poor opacification of arterial structures in the hand. Because of advanced ischemia, soft tissue infection and osteomyelitis, a distal forearm amputation was indicated. Hand threatening ischemia secondary to steal phenomenon associated to AVMs in PWS is rarely encountered and reported. This case illustrates a complex clinical presentation with advanced disease that required limb amputation.