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Relevant clinical history and physical exam
A 58 years-old woman suffered from paleness on her left hand during hemodialysis for several years. She presented to our hospital with an intractable skin ulcer emerged on her left 3rd finger (Figure 1), regardless of an antibiotic therapy and debridement at a nearby medical clinic. She had a history of hemodialysis over several years, polymyalgia rheumatic (PMR) and RS3PE syndrome treated with 5mg prednisolone.
Relevant test results prior to catheterization
On examination, vital sign was within normal range. She had an arteriovenous fistula (AVF) at left forearm, but the thrill was weak. Her left 3rd fingertip was ulcerative. Skin perfusion pressure (SPP) at her 3rd fingertip was 19 mmHg. Meanwhile we made a diagnosis of giant cell arteritis(GCA) based on bilateral temporal artery biopsy, because of bilateral temporal artery hyperplasia and a history of PMR.
Relevant catheterization findings
The Preoperative angiography showed occluded proximal left radial artery, no communication between ulnar and superficial palmer artery, too many collateral from left ulnar to radial artery, and the absence of finger arteries visualization (Figure 2).
A following local anesthesia, the 4.5Fr guiding sheath inserted from the right femoral artery, and. delivered to left brachial artery. 0.014 inch Gradius wire (ASAHI INTECC., Japan) was able to penetrate antegrade the occlusive lesion at the proximal left radial artery. We tried to aspirate the occlusive lesion, but there was no thrombus. The lesion was dilated 4.0 mm scoring balloon and used a drug coated balloon (Sequent Please 4.0 x 20 mm). Successful endovascular therapy (EVT) to the occluded radial artery apparently increased flow to arteriovenous fistula (AVF) but did not improve flow to her fingertips (Figure 3). Slightly compressed AVF obviously augmented flow to her fingertips, which reached a diagnosis of hemodialysis access-induced distal ischemia (HAIDI) (Figure 4). Then, Surgical AVF banding improved SPP value at the finger up to 34 mmHg, resulted in complete wound healing completely (Figure 5)
At first, as arterial involvement in GCA patients with upper extremity vasculitis commonly distributed in a large or medium vessel, small vessel involvement such as radial or ulnar artery is unusual.
Secondly, there has been no report that combination of surgical AVF banding and EVT helped ischemic skin ulcer due to HAIDI healed. To make a precise diagnosis of hemodialysis access-induced distal ischemia (HAIDI) and to evaluate essential blood flow to wound healing, angiogram under compressed AVF is required.