In patients receiving cardiac resynchronization therapy (CRT), the left ventricular electrode cannot always be positioned in the preferred lateral or posterolateral locations due to technical factors and anatomic variations in the coronary sinus. Recent reports also suggest that CRT outcomes are improved by pacing the site of latest dyssynchrony and accessing these regions is not always possible. We report the utility of applying a technique described in the interventional literature over the past 3 years, effectively traversing and dilating collateral channels. Our patients demonstrated either no venous targets in the optimal location, or problems accessing this location using a antegrade approach. Subsequently, collaterals supplying this region were traversed with a guidewire using a retrograde approach and dilated with a balloon catheter. In the first case, the pacing electrode was then advanced in similar fashion and successfully positioned in an ideal lateral location. In the second case, the retrograde guidewire was captured with a vascular snare and pulled into a second guiding catheter, allowing appropriate dilatation and stenting of a problematic proximal venous stenosis with resultant facile placement of the pacing electrode. This technique offers a potential alternative to patients with challenging venous anatomy as a method to facilitate optimal CRT outcomes.

(J Interven Cardiol 2009;22:27-36).

BACKGROUND:The combination of glycoprotein (GP) IIb-IIIa inhibition and direct thrombin inhibition (DTI) with bivalirudin (Angiomax, The Medicines Company, Cambridge, Massachusetts) have shown ischemic and hemorrhagic outcomes benefit in coronary interventions and may have similar benefits in percutaneous peripheral interventions (PPI). The high incidence of diabetes, chronic renal disease, platelet dysfunction, hypercoagulability, inflammation and a thrombus-rich environment make a GP IIb-IIIa and DTI combination with tirofiban (Aggrastat Merck and Company, Inc., Whitehouse Station, New Jersey) an attractive anticoagulation strategy in the PPI treatment of critical limb ischemia (CLI).METHODS:Between May 1, 2001 and January 31, 2003, a CLI treatment group of 149 patients received PPI with bivalirudin (0.75 mg per kg bolus with 1.75 mg per kg per hour periprocedural infusion) and tirofiban (10 mcg per kg per minute bolus with 12-hour 0.1 mcg per kg per minute infusion) as an anticoagulation and antiplatelet strategy, and were compared to a matched unfractionated heparin (UFH) control group without GP IIb-IIIa inhibitors. Clinical and hemostasis outcomes were analyzed, including distal embolization (DE).RESULTS:Procedural success was 95.9% and 97.3% in the UFH control group and DTI-GP IIb-IIIa group, respectively. Significant differences were observed in the sheath removal time < 2 hours (60.5% UFH group versus 19.4% DTI-GP IIb-IIIa group; p = < 0.0001). Vascular closure devices were used equally in both groups. No statistical significance was observed in major and minor complications, femoral access complications, acute (< 48 hours) or subacute (30 days) vessel thrombosis, and 6-month duplex ultrasound restenosis rate between the DTI-GP IIb-IIIa versus the UFH group. A trend towards statistical significance was observed in the 6-month secondary re-intervention and limb salvage rates (10.7% versus 18.8%; p = 0.0501 and 93.9% versus 88.5%; p = 0.053) in the DTI-GP IIb-IIIa versus the UFH group, respectively. Angiographically relevant DE occurred in 4 of 149 (1.3%) and 8 of 149 (5.4%) of the bivalirudin-tirofiban and UFH groups, respectively.CONCLUSION:The combination of DTI with bivalirudin and GP IIb-IIIa inhibition with tirofiban is a safe and feasible alternative anticoagulation and antiplatelet strategy in PPI, and may offer improved clinical and hemostasis outcomes in treating CLI. A larger, prospective randomized trial is warranted.

BACKGROUND:Multiple reports document the higher costs of primary amputation (PA) compared to infrainguinal bypass surgery (IBS). Recent reports document 40-50% cost-effectiveness for percutaneous transluminal angioplasty (PTA) compared to IBS. The literature suggests appropriate initial treatment for critical limb ischemia (CLI) to be IBS = 38%, PTA = 28%, and PA = 16%. The encouraging 6-month Laser Angioplasty for Critical Limb Ischemia (LACI) 93% limb salvage rate prompted an independent CLI and LACI clinical and economic analysis.METHODS:Between 1999-2001 a reference amputation population (RAP) of 417 patients with at least one infrainguinal amputation were identified from a 2.5 million patients Medicare/insurance dataset. Clinical data and all medical cost claims for 18 continuous months, 12-month prior and 6-month post-amputation, were analyzed for PTA, IBS, and PA treatment pathways. Based on multiple assumptions and the LACI phase II results, economic outcomes were used for a LACI pathway analysis compared to PTA, IBS and PA pathways by substituting the LACI trial pathway as the initial treatment in lieu of the RAP actual treatment.RESULTS:Initial treatments for CLI RAP were PA = 67%, IBS = 23%, PTA = 10%; A majority of wound complications (80%) and myocardial infarction 7/9 (77.7%), stroke 13/16 (81.2%), and death 2/2 (100%) occurred in the PA RAP. Only 35% of the RAP had an ankle brachial index (ABI) and only 16% angiography before PA. 227/417 (56%) of the RAP had multiple procedures. Average total costs / patient = $31,638 without LACI and $25,373 with LACI. Average savings/patient with LACI = $6,265.CONCLUSION:The most common current treatments in the US for CLI are still characterized by high rates of primary amputations, multiple procedures, and high rates of procedure-related complications. Despite the limitations and assumptions of this analysis, the utilization of a LACI pathway first revascularization treatment strategy may provide clinical and economic cost savings in treating patients with CLI.

HomeCirculationVol. 105, No. 13Hypothenar Hammer Syndrome Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBHypothenar Hammer Syndrome Ravindra Sharma, MD, William Ladd, MD, Gary Chaisson and Richard Abben, MD Ravindra SharmaRavindra Sharma From the Terrebonne General Medical Center, Cardiovascular Institute of the South, Houma, La. Search for more papers by this author , William LaddWilliam Ladd From the Terrebonne General Medical Center, Cardiovascular Institute of the South, Houma, La. Search for more papers by this author , Gary ChaissonGary Chaisson From the Terrebonne General Medical Center, Cardiovascular Institute of the South, Houma, La. Search for more papers by this author and Richard AbbenRichard Abben From the Terrebonne General Medical Center, Cardiovascular Institute of the South, Houma, La. Search for more papers by this author Originally published2 Apr 2002https://doi.org/10.1161/hc1302.104526Circulation. 2002;105:1615–1616A 50-year-old air-conditioning repairman presented to our emergency room with a 12-hour history of progressively worsening pain, decreased temperature, and bluish discoloration involving the third right finger. The patient denied a history of prior cardiovascular problems but did smoke tobacco heavily. Careful questioning revealed that he often utilized his hand as a “hammer” and had been particularly vigorous with this technique a few days prior to admission. Physical examination demonstrated ischemic changes in the tip of the middle finger of his right hand. An x-ray (Figure 1) of the right hand demonstrated an old un-united fracture of the ulnar styloid. He was treated with intravenous heparin and underwent angiography of the right upper extremity via the right femoral approach. The study demonstrated subtotal occlusion of the right ulnar artery at the wrist with poor filling of the digital arteries supplying the lateral 3 fingers (arrows, Figure 2). The results were compatible with hypothenar hammer syndrome, a term first coined by Conn et al1 in 1970 although Guttani2,3 (1772) and Von Rosen2,4,5 (1934) had previously described similar cases. The syndrome is seen in the dominant hand of males who, during occupational or recre-ational activities, use their hand as a hammer. The mechanism of the injury relates to repetitive trauma to the superficial division of the ulnar artery in the hypothenar region of the hand. He was treated with several boluses of nitroglycerin, verapamil, and papaverine administered into the brachial artery. Repeat angiography demonstrated improved filling. His symptoms improved over the next 24 hours and did not recur. He was discharged on a regimen of subcutaneous dalteparin for 5 days and oral aspirin, clopidogrel, and nifedipine. He was also advised to quit smoking and refrain from using his hand in the manner described. Download figureDownload PowerPointFigure 1. Radiograph of right hand showing old un-united fracture of ulnar styloid.Download figureDownload PowerPointFigure 2. Photograph showing subtotal occlusion of right ulnar artery with poor filling of digital arteries supplying third, fourth, and fifth fingers.The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.FootnotesCorrespondence to Ravindra Sharma, MD, FACC, Terrebonne General Medical Center, Cardiovascular Institute of the South, 315 Liberty St, PO Box 4176, Houma, LA 70361-4176.References1 Conn J Jr, Bergan JJ, Bell JL. Hand ischemia: hypothenar hammer syndrome. Proc Inst Med Chicago. 1970; 28: 83.Google Scholar2 Aulicino PL, Hutton PM, DuPuy TE. True palmar aneurysms: a case report and literature review. J Hand Surgery. 1982; 7: 613–616.CrossrefGoogle Scholar3 Guttani C. De Externis Aneurysmatibus Manu Chirurgica Methodice Pertractandis, 1772. Erichsen JE, trans. Observations on Aneurysms. London: Sydentham Society; 1884;316–318.Google Scholar4 Von Rosen S. Ein Fall Von Thrombose in der Arteria Ulnaris nach Einwirkung von Stumper Gewalt. ACTA Chir Scand. 1934; 73: 500–506.Google Scholar5 Vayssairat M. Hypothenar hammer syndrome: seventeen cases with long-term follow-up. J Vasc Surg. 1987; 5: 838–843.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Helsper E and Goldfarb C (2022) Vascular Injuries of the Hand and Wrist Hand and Wrist Injuries in Baseball, 10.1007/978-3-030-81659-9_17, (217-227), . Wahl U (2020) Organische und funktionelle Durchblutungsstörungen der Hand – differenzialdiagnostische Aspekte, Phlebologie, 10.1055/a-1170-9250, 49:04, (233-241), Online publication date: 1-Aug-2020. Iannuzzi N and Higgins J (2015) Acute Arterial Thrombosis of the Hand, The Journal of Hand Surgery, 10.1016/j.jhsa.2015.04.015, 40:10, (2099-2106), Online publication date: 1-Oct-2015. de Mooij T, Duncan A and Kakar S (2015) Vascular Injuries in the Upper Extremity in Athletes, Hand Clinics, 10.1016/j.hcl.2014.09.004, 31:1, (39-52), Online publication date: 1-Feb-2015. Queiroz M, Pereira L, Picanço C, Luna R, Costa F and Silveira C (2013) Hypothenar hammer syndrome: case report and literature review, Revista Brasileira de Ortopedia (English Edition), 10.1016/j.rboe.2012.05.003, 48:1, (104-107), Online publication date: 1-Jan-2013. Queiroz M, Pereira L, Picanço C, Luna R, Costa F and Silveira C (2013) Síndrome do martelo hipotenar: relato de caso e revisão da literatura, Revista Brasileira de Ortopedia, 10.1016/j.rbo.2012.10.004, 48:1, (104-107), Online publication date: 1-Jan-2013. Yuen J, Wright E, Johnson L and Culp W (2011) Hypothenar Hammer Syndrome, Annals of Plastic Surgery, 10.1097/SAP.0b013e31820859e1, 67:4, (429-438), Online publication date: 1-Oct-2011. Cigna E, Spagnoli A, Tarallo M, De Santo L, Monacelli G and Scuderi N (2010) Therapeutic Management of Hypothenar Hammer Syndrome Causing Ulnar Nerve Entrapment, Plastic Surgery International, 10.1155/2010/343820, 2010, (1-5), Online publication date: 7-Jun-2010. Lin T, Huang F, Chen C, Shih H and Hsieh C (2007) Multiple Digital Gangrene after a Radial Artery Penetrating Injury: A Case Report, Annals of Vascular Surgery, 10.1016/j.avsg.2006.06.011, 21:3, (384-387), Online publication date: 1-May-2007. Marie I, Hervé F, Primard E, Cailleux N and Levesque H (2007) Long-Term Follow-Up of Hypothenar Hammer Syndrome, Medicine, 10.1097/MD.0b013e31815c95d3, 86:6, (334-343), Online publication date: 1-Nov-2007. White W and Parke A (2005) Acute pain in the tip of the index finger, The American Journal of Medicine, 10.1016/j.amjmed.2005.08.036, 118:11, (1223-1224), Online publication date: 1-Nov-2005. Jud P, Pregartner G, Berghold A, Rief P, Muster V, Gütl K, Brodmann M and Hafner F (2021) Endovascular Thrombolysis in Hypothenar Hammer Syndrome: A Systematic Review, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2021.745776, 8 April 2, 2002Vol 105, Issue 13 Advertisement Article InformationMetrics https://doi.org/10.1161/hc1302.104526 Originally publishedApril 2, 2002 PDF download Advertisement