Surgical Treatment of Distal Ulnar Artery Aneurysm E. John Harris, Jr., MD, Lloyd M. Taylor, Jr., MD, James M. Edwards, MD, Joseph L. Mills, MD, John M. Porter, MD, Portland, Oregon In the past 7 years, we have encountered six pa- tients with finger ischemia as a result of digital ar- tery occlusion associated with seven distal ulnar ar- tery aneurysms. Our experience with the management of these patients forms the basis of this report. All patients were men, with a mean age of 29 years, and all experienced repetitive trauma to the involved upper extremity. Each patient pre- sented with the acute onset of cool and painful dig- its, with no previous history of cold sensitivity or Raynaud's syndrome. None of the patients had any serologic or clinical evidence of autoimmune dis- ease. Angiography revealed occlusion of the ulnar artery on the affected side in two patients and pat- ent ulnar artery aneurysms in the remaining five patients. There was occlusion of multiple common and proper digital arteries in all patients. One pa- tient with bilateral ulnar artery aneurysms under- went operative repair consisting of aneurysm exci- sion and replacement with autogenous vein grafts from the lower extremity. All patients have im- proved symptoms, and the grafts remained patent over a mean follow-up of 24 months (range: 13 to 57 months). Based on these results, we recommend that excision and grafting be considered for patients with symptomatic patent ulnar artery aneurysms. Selected patients with thrombosed aneurysms with ongoing digital ischemia may also benefit from sur- gical intervention. A vailable evidence indicates that about half of the pa- tients presenting with symptomatic hand and finger ischemia have one or more of a variety of systemic disease processes, of which autoimmune diseases are the most frequent. Many of these patients have as one of their From the Divisionof Vascular Surgery,Departmentof Surgery,Ore- gon HealthSciences University, Portland, Oregon. Supported in part by grant R000334 from the Clinical Research Center Branch, National Institutes of Health, Bethesda,Maryland. Requests for reprintsshouldbe addressedto LloydM. Taylor,Jr., MD, Oregon HealthSciences University, 3181S.W. Sam JacksonPark Road, Portland,Oregon97201-3098. Presentedat the 76th Annual Meetingof the North PacificSurgi- cal Association, Victoria,BritishColumbia, Canada,November10-11, 1989. manifestations occlusion of palmar and digital arteries. The remaining half of patients with digital ischemia have potentially correctable arterial obstruction proximal to the superficial palmar arch. Ulnar artery aneurysms, with or without thrombosis, are an uncommon but well-recognized cause of digital ischemia, usually from digital artery embolization. The most common presenting complaint is the sudden onset of Raynaud's syndrome of the affected digits. Patients frequently give a history of repeated hypoth- enar trauma, as is commonly seen in carpenters and me- chanics who use this portion of their hand as a hammer. The repetitive trauma presumably causes intimal damage with aneurysm formation and thrombosis [1]. Neurolog- ic symptoms from irritation of the adjacent ulnar nerve may be seen [2]. The clinical syndrome, including hand ischemia with repetitive blunt hypothenar trauma, has been identified [3-6] and was labeled the "hypothenar hammer syndrome" by Corm and co-workers [7]. In the past 7 years, we have encountered six patients with finger ischemia as a result of digital artery occlusion associated with seven distal ulnar artery aneurysms. Our experience with the management of these patients forms the basis of this report. MATERIAL AND METHODS Over the past two decades, the Division of Vascular Surgery at Oregon Health Sciences University has pro- spectively studied more than 1,000 patients with hand and finger ischemia. A number of routine tests were ob- tained on each patient including complete blood count, erythrocyte sedimentation rate, multi-chemical panel, anti-nuclear antibody, serum protein electrophoresis, rheumatoid factor, cold agglutinin, and hepatitis serolo- gY. Each of these six patients underwent arteriography from the aortic arch to the fingertips, using the transfem- oral Seldinger approach for selective axillary artery cath- eterization. Both upper extremities were studied to pro- vide comparison. Magnification hand arteriograms were obtained before and after cold exposure and tolazoline challenge, as previously described [8]. A representative hand arteriogram appears in Figure 1, illustrating a distal ulnar artery aneurysm with embolization to digital arter- ies. In each patient, the ulnar artery was exposed using a longitudinal incision from the wrist crease to the superfi- cial palmar arch. The ulnar aneurysm was mobilized and excised. Autogenous vein was interposed in an end-to-end fashion. Vein grafts were obtained from the foot or from calf or ankle branches of the greater saphenous vein. The electromagnetic flow meter was used to confirm adequate THE AMERICAN JOURNAL OF SURGERY VOLUME159 MAY 1990 527