A Case of Intra-arterial Thrombolysis with Alteplase
in a Patient with Hypothenar Hammer Syndrome but without Underlying Aneurysm
Authors: Harshal Shukla, PharmD, BCPS, Vicken
Yaghdjian, PharmD, Issam Koleilat, MD
Hypothenar hammer syndrome is a cause of
symptomatic ischemia of the hand secondary to the formation of aneurysm or
thrombosis of the ulnar artery in the setting of a complete or
incomplete palmar arch.1 Acute occlusive thrombus or
embolus of the hand represents a complex problem that often may require
immediate surgical intervention. We report a case of acute unilateral
arterial hand ischemia requiring catheter-directed thrombolysis with Alteplase
therapy in a patient with acute occlusive arterial thrombosis of the left ulnar
artery. A catheter-directed thrombolytic regimen consisted of
Alteplase 1 milligram per hour for 24 hours and heparin was
infused through the sheath side arm at a rate of 500 units per hour for
resolution of the thrombus and improvement in symptoms.
A former truck driver presented with worsening pain
and subsequent development of significant cyanosis with early gangrenous
changes of the left second and third fingertips. He had significant callous of
the 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. Initial
angiogram revealed only ulnar artery occlusion at the wrist with reconstitution
just distal to the hypothenar eminence. Twenty-four hours after the initiation
of thrombolysis, repeat angiography revealed resolution with a widely patent
ulnar artery. His symptoms and the color of his digits immediately
improved and within a few months his hand had normalized. The
patient had no clinical sequelae of thrombolytic therapy.
Catheter-directed thrombolytic therapy in situations
of acute occlusive thrombus of the hand may provide a therapeutic option for
patients with suspected hypothenar hammer syndrome. However, thrombolytic
therapy carries risk of significant hemorrhagic complications. Before
initiating therapy, careful judgment about the possibility for bleeding risk is
required. This provides for a minimally invasive alternative to open surgical
revascularization especially in the absence of underlying correctable anatomic
defect such as aneurysm.
STATEMENT OF CONSENT
The patient described herein had given consent to the
use of deidentified patient data for use in research and education.
occlusive syndromes of the upper extremity are rare and often secondary to
repetitive trauma, atherosclerosis, embolic events and hypercoagulable states.
The symptoms can include pain, paresthesias and cold intolerance.1 Hypothenar
hammer syndrome occurs when repetitive impact to the palmar aspect of the wrist
and hand at the hypothenar eminence causes damage to the underlying ulnar
artery. 2 This damage may manifest clinically as in situ thrombosis or distal embolization
with or without underlying aneurysm. This results in acute ischemia of the
digits. Typically, this occurs in the setting of an incomplete palmar arch and
therefore an inability of the radial artery to compensate for the ischemia.
hammer syndrome may occur in sports and occupations where the heel of the hand
is used as a hammer or is subject to repeated force. Besides cases of acute
trauma, it may occur in the dominant hand of players of racquet, stick, and
club sports; volleyball players; and practitioners of the martial arts. Other
occupations 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 unilateral
symptoms which upon physical exam are suggestive of vascular pathology.
Angiography is diagnostic. Conservative approaches such as cessation of
offending activity, calcium channel blockers, antiplatelet therapy or
anticoagulants are appropriate in most patients, whereas surgical options and
thrombolytic therapy are reserved for patients with severe or refractory
report a case of acute unilateral hand arterial ischemia requiring
catheter-directed thrombolysis with Alteplase therapy in a patient with acute
occlusive thrombus of left distal ulnar artery likely secondary to use of a
cane and truck driving.
Figure 1: Initial angiogram revealing occlusion of the ulnar
artery distally at the wrist.
Figure 2: Angiogram after 20 hours of thrombolytic infusion
revealing complete recanalization with filling of the digital arteries
A 57 year-old
gentleman presented to the emergency department with a 1.5 week history of
progressively worsening pain and swelling that began in left hand and
progressed to 2-5th distal interphalangeal joints (DIP). Initially, he felt
that his fingers started to feel numb, which went away as the day progressed.
However, several days prior to presentation he noted persistent numbness with
new discoloration of his fingertips that began to worsen as well. Upon
presentation to the hospital, his left ulnar pulse was not palpable and his
left 2-5th fingertips appeared deeply cyanotic with early gangrenous changes.
He denied any other symptoms.
had a past medical history significant for anxiety, depression, alcohol abuse, and
chronic back pain.
He was an active smoker of about 16 pack-years. He also had a remote history of
heroin 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 hand
despite being right-hand dominant.
examination, his left 2-5th fingertips appeared profoundly cyanotic with early
gangrenous changes. His fingers were cool to the touch. He had decreased
sensation in left hand and was unable to make a fist. His left radial pulse was
palpable but the ulnar pulse was not. His physical exam including contralateral
arm neurovascular exam was otherwise unremarkable. He had a Doppler signal in
the distal ulnar artery and in the palmar arch. Duplex examination of the upper
extremity revealed an acute occlusive thrombus of the left distal ulnar artery
suggestive of hypothenar hammer syndrome. He was taken for angiographic
from a right femoral retrograde approach revealed normal left upper extremity
arterial tree with the exception of an ulnar occlusion at the wrist. The wire crossed the occlusion
easily consistent with acute thrombosis. The deep arch and digital vessels
reconstituted distally. Aspiration with a glide catheter yielded thrombus.
Thrombolysis was therefore initiated with a 4 French UniFuse catheter with an
infusion length of 20 cm. It was placed in the ulnar artery distally with about
5 cm hanging into the brachial artery across the bifurcation proximally.
thrombolytic regimen consisted of Alteplase 1 milligram (mg) per hour and
intravenous heparin. Heparin was infused through the sheath sidearm at a rate
of 500 units per hour. He was admitted to the intensive
care unit where all patients undergoing thrombolytic infusions are observed per
protocol. Repeat angiography was conducted after about 20 hours of
infusion (about 20mg of Alteplase). This revealed a
widely patent ulnar artery and resolution of the thrombus with antegrade
filling of the deep palmar arch. The digital vessels were seen now to continue
from the arch to the digits. The ulnar artery appeared overall normal without
corkscrew appearance. This confirmed the diagnosis of hypothenar hammer
syndrome with ulnar artery occlusion but without underlying aneurysm. The
thrombolytic infusion was discontinued but therapeutic anticoagulation was
subsequently 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 that
hammer syndrome is a rare cause of symptomatic ischemia of the hand secondary
to trauma. It manifests clinically in many ways including thrombosis or distal
embolization of the ulnar artery with or without underlying aneurysm. Acute
occlusive thrombus of the hand represents a complex problem that often may
require immediate surgical intervention. Catheter-directed thrombolytic therapy
with Alteplase can be a therapeutic option for these patients. Overall,
favorable outcomes have been shown when thrombolysis is performed in the acute
setting with angiographic or clinical improvement nearly 80 percent of the
time. 5 This is particularly
advantageous given that angiographic endovascular intervention can obviate the
need for open surgery. Open surgical treatment involving thrombectomy can
result in a longer post-intervention recovery due to the surgical incision,
especially if this involves the dominant hand. Additionally, in situations of
distal embolization it may be difficult to fully evacuate the embolic material
due 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.
significant benefit, thrombolytic therapy carries risk of significant
hemorrhagic complications. The most feared of these is debilitating hemorrhagic
stroke. Before initiating therapy, careful judgment and discussion with the
patient about the possibility for bleeding risk is required. The overall
complication rates for upper extremity thrombolytic therapy can reportedly
range from 0 to 75 percent of patients treated. Nearly half of the reported
cases have no complications but the remaining series report a pooled
complication rate of about 18 percent. The incidence of amputations appears to
be less than 10 percent. 5
thrombolytic therapy is a useful and important tool in the armamentarium for
the treatment of acute limb-threatening events. While off-label, discussion of
the potential complications and thorough risk-benefit analysis with the patient
may provide for an excellent alternative to open surgical revascularization.
Alteplase infusion for acute limb-threatening ischemia, even in the upper
extremity, can provide an excellent option to treat hypothenar hammer syndrome
especially without underlying correctable anatomic defect such as aneurysm.
of Conflicting Interests:
The author(s) declared no potential
conflicts of interest with respect to the research, authorship and/or
publication of this article.
The author(s) received no financial
support for the research, authorship and/or publication of this article.
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