PMC5248565_01
Ulceration on the palmar surface of the left thumb (A), small punctate ulcerations on other fingers and distal phalanx necrosis of the right thumb (B).
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The largest ulceration measuring 10 over 20 mm was located on the palmar surface of the left thumb (Figure 1A). Small punctate ulcerations with a maximum diameter of 3 mm were also noted on other fingers (Figure 1B). Distal phalanx necrosis of the right thumb had 15 mm (Figure 1B).
(A-D) Right upper extremity arteriography. Hemodynamically insignificant ostial stenosis of the right subclavian artery (white arrow). Axillary (blue arrow), brachial (red arrow) and intercostal (brown arrow) arteries are patent without significant stenosis. Radial artery occlusion (green arrow); ulnar artery (yellow arrow) is patent in the proximal part, the middle part is occluded and the distal part fills up from collaterals. Ulnar artery (yellow arrow) remains the main supply for the hand arches.
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On arteriography of the right upper extremity performed from right femoral access we noticed a hemodynamically-insignificant calcified ostial stenosis of the right subclavian artery (Figure 2A). Axillary, brachial and intercostal arteries were patent without significant stenosis (Figure 2A, 2B). Radial artery was occluded; ulnar artery was patent in the proximal part, the middle part was occluded and the distal part filled up from collaterals (Figure 2C). Ulnar artery remained the main supply for the hand arches (Figure 2D).
Endovascular recanalization of ulnar artery occlusion. Arteriography before treatment - ulnar artery (yellow arrow) and radial artery (green arrow) occlusion (A). The guidewire (V18) was advanced to the ulnar artery (orange arrow - B). The final angiographic result shows recanalization of the ulnar artery (yellow arrow - C, D).
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On angiography, radial artery was completely occluded, ulnar artery was patent in its proximal and distal part with a 10-cm calcified occlusion in the middle part (Figure 3A). Occlusion was crossed with a V18 wire and dilated using a 2/120mm Biotronic Passeo 18 angioplasty balloon (12 atm) (Figure 3B, 3C). After angioplasty, good inflow to hand arterial arches was observed (Figure 3D).