A patent ulnar artery. His symptoms and

A Case of Intra-arterial Thrombolysis with Alteplasein a Patient with Hypothenar Hammer Syndrome but without Underlying Aneurysm Authors: Harshal Shukla, PharmD, BCPS, VickenYaghdjian, PharmD, Issam Koleilat, MD Abstract: Hypothenar hammer syndrome is a cause ofsymptomatic ischemia of the hand secondary to the formation of aneurysm orthrombosis of the ulnar artery in the setting of a complete orincomplete palmar arch.1 Acute occlusive thrombus orembolus of the hand represents a complex problem that often may requireimmediate surgical intervention. We report a case of acute unilateralarterial hand ischemia requiring catheter-directed thrombolysis with Alteplasetherapy in a patient with acute occlusive arterial thrombosis of the left ulnarartery.

A catheter-directed thrombolytic regimen consisted ofAlteplase 1 milligram per hour for 24 hours and heparin wasinfused through the sheath side arm at a rate of 500 units per hour forresolution of the thrombus and improvement in symptoms. A former truck driver presented with worsening painand subsequent development of significant cyanosis with early gangrenouschanges of the left second and third fingertips. He had significant callous ofthe hypothenar eminence and reported that not only was his left hand his”driving” hand but he also used a cane in his left hand to ambulate. Initialangiogram revealed only ulnar artery occlusion at the wrist with reconstitutionjust distal to the hypothenar eminence. Twenty-four hours after the initiationof thrombolysis, repeat angiography revealed resolution with a widely patentulnar artery. His symptoms and the color of his digits immediatelyimproved and within a few months his hand had normalized. Thepatient had no clinical sequelae of thrombolytic therapy. Catheter-directed thrombolytic therapy in situationsof acute occlusive thrombus of the hand may provide a therapeutic option forpatients with suspected hypothenar hammer syndrome.

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However, thrombolytictherapy carries risk of significant hemorrhagic complications. Beforeinitiating therapy, careful judgment about the possibility for bleeding risk isrequired. This provides for a minimally invasive alternative to open surgicalrevascularization especially in the absence of underlying correctable anatomicdefect such as aneurysm. STATEMENT OF CONSENTThe patient described herein had given consent to theuse of deidentified patient data for use in research and education. Introduction:Vascularocclusive syndromes of the upper extremity are rare and often secondary torepetitive trauma, atherosclerosis, embolic events and hypercoagulable states.The symptoms can include pain, paresthesias and cold intolerance.1 Hypothenarhammer syndrome occurs when repetitive impact to the palmar aspect of the wristand hand at the hypothenar eminence causes damage to the underlying ulnarartery. 2 This damage may manifest clinically as in situ thrombosis or distal embolizationwith or without underlying aneurysm.

This results in acute ischemia of thedigits. Typically, this occurs in the setting of an incomplete palmar arch andtherefore an inability of the radial artery to compensate for the ischemia.Hypothenarhammer syndrome may occur in sports and occupations where the heel of the handis used as a hammer or is subject to repeated force. Besides cases of acutetrauma, it may occur in the dominant hand of players of racquet, stick, andclub sports; volleyball players; and practitioners of the martial arts. Otheroccupations such as auto mechanics, metal workers, miners, machinists,butchers, bakers, carpenters, and brick layers are also at risk. 3 It typically occurs in middle-aged men who present with unilateralsymptoms which upon physical exam are suggestive of vascular pathology.

Angiography is diagnostic. Conservative approaches such as cessation ofoffending activity, calcium channel blockers, antiplatelet therapy oranticoagulants are appropriate in most patients, whereas surgical options andthrombolytic therapy are reserved for patients with severe or refractorysymptoms. 4Wereport a case of acute unilateral hand arterial ischemia requiringcatheter-directed thrombolysis with Alteplase therapy in a patient with acuteocclusive thrombus of left distal ulnar artery likely secondary to use of acane and truck driving.                     Figure 1:                                                                                            Figure 2:                                                 Figure 1: Initial angiogram revealing occlusion of the ulnarartery distally at the wrist.Figure 2: Angiogram after 20 hours of thrombolytic infusionrevealing complete recanalization with filling of the digital arteriesdistally.Case:A 57 year-oldgentleman presented to the emergency department with a 1.5 week history ofprogressively worsening pain and swelling that began in left hand andprogressed to 2-5th distal interphalangeal joints (DIP). Initially, he feltthat his fingers started to feel numb, which went away as the day progressed.

However, several days prior to presentation he noted persistent numbness withnew discoloration of his fingertips that began to worsen as well. Uponpresentation to the hospital, his left ulnar pulse was not palpable and hisleft 2-5th fingertips appeared deeply cyanotic with early gangrenous changes.He denied any other symptoms.Hehad a past medical history significant for anxiety, depression, alcohol abuse, andchronic back pain.He was an active smoker of about 16 pack-years. He also had a remote history ofheroin and cocaine use and his last relapse was documented over 10 years ago. He was a former truck driver who drove mostly with his left handdespite being right-hand dominant.Onexamination, his left 2-5th fingertips appeared profoundly cyanotic with earlygangrenous changes.

His fingers were cool to the touch. He had decreasedsensation in left hand and was unable to make a fist. His left radial pulse waspalpable but the ulnar pulse was not. His physical exam including contralateralarm neurovascular exam was otherwise unremarkable.

He had a Doppler signal inthe distal ulnar artery and in the palmar arch. Duplex examination of the upperextremity revealed an acute occlusive thrombus of the left distal ulnar arterysuggestive of hypothenar hammer syndrome. He was taken for angiographicassessment.Angiographyfrom a right femoral retrograde approach revealed normal left upper extremityarterial tree with the exception of an ulnar occlusion at the wrist. The wire crossed the occlusioneasily consistent with acute thrombosis.

The deep arch and digital vesselsreconstituted distally. Aspiration with a glide catheter yielded thrombus.Thrombolysis was therefore initiated with a 4 French UniFuse catheter with aninfusion length of 20 cm. It was placed in the ulnar artery distally with about5 cm hanging into the brachial artery across the bifurcation proximally.

The catheter-directedthrombolytic regimen consisted of Alteplase 1 milligram (mg) per hour andintravenous heparin. Heparin was infused through the sheath sidearm at a rateof 500 units per hour. He was admitted to the intensivecare unit where all patients undergoing thrombolytic infusions are observed perprotocol. Repeat angiography was conducted after about 20 hours ofinfusion (about 20mg of Alteplase). This revealed awidely patent ulnar artery and resolution of the thrombus with antegradefilling of the deep palmar arch. The digital vessels were seen now to continuefrom the arch to the digits. The ulnar artery appeared overall normal withoutcorkscrew appearance.

This confirmed the diagnosis of hypothenar hammersyndrome with ulnar artery occlusion but without underlying aneurysm. Thethrombolytic infusion was discontinued but therapeutic anticoagulation wassubsequently continued and the patient was discharged on rivaroxaban therapy. The patient was initially given rivaraxoban therapy of 15 milligram(mg) twice daily for 21 days followed by 20 mg once daily and continues on thatdose.   Discussion:Hypothenarhammer syndrome is a rare cause of symptomatic ischemia of the hand secondaryto trauma.

It manifests clinically in many ways including thrombosis or distalembolization of the ulnar artery with or without underlying aneurysm. Acuteocclusive thrombus of the hand represents a complex problem that often mayrequire immediate surgical intervention. Catheter-directed thrombolytic therapywith Alteplase can be a therapeutic option for these patients. Overall,favorable outcomes have been shown when thrombolysis is performed in the acutesetting with angiographic or clinical improvement nearly 80 percent of thetime. 5 This is particularlyadvantageous given that angiographic endovascular intervention can obviate theneed for open surgery. Open surgical treatment involving thrombectomy canresult in a longer post-intervention recovery due to the surgical incision,especially if this involves the dominant hand. Additionally, in situations ofdistal embolization it may be difficult to fully evacuate the embolic materialdue to its small nature and distal position, within the small digital arteries.Alteplase infusion is an alternative that is not vulnerable to these concerns.

While open surgery may still be required to treat any underlying aneurysm,angiography as a first step allows for additional treatment options.Despite thesignificant benefit, thrombolytic therapy carries risk of significanthemorrhagic complications. The most feared of these is debilitating hemorrhagicstroke. Before initiating therapy, careful judgment and discussion with thepatient about the possibility for bleeding risk is required. The overallcomplication rates for upper extremity thrombolytic therapy can reportedlyrange from 0 to 75 percent of patients treated. Nearly half of the reportedcases have no complications but the remaining series report a pooledcomplication rate of about 18 percent.

The incidence of amputations appears tobe less than 10 percent. 5 Conclusion:Catheter-directedthrombolytic therapy is a useful and important tool in the armamentarium forthe treatment of acute limb-threatening events. While off-label, discussion ofthe potential complications and thorough risk-benefit analysis with the patientmay provide for an excellent alternative to open surgical revascularization.Alteplase infusion for acute limb-threatening ischemia, even in the upperextremity, can provide an excellent option to treat hypothenar hammer syndromeespecially without underlying correctable anatomic defect such as aneurysm.    Declarationof Conflicting Interests: The author(s) declared no potentialconflicts of interest with respect to the research, authorship and/orpublication of this article.

 Fundings: The author(s) received no financialsupport for the research, authorship and/or publication of this article. References:1. Wilhelmi B. Vascular Occlusive Syndromes of theUpper Extremity Treatment and Management. Medscape website.http://emedicine.

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