European Journal of Plastic Surgery

, Volume 42, Issue 2, pp 205–210 | Cite as

A rare case of finger ischemia following bypass procedure with autologous vein graft for thumb revascularization: a case report and brief review of the literature

  • Norman Della RosaEmail author
  • Nicolò Bertozzi
  • Giulia Colzani
  • Roberto Adani
Case Report


This case report aims to point out the importance of having in mind anatomical variation in the blood supply to the hand even in emergency settings. A 39-year-old patient presented at our emergency department with a wound on the distal anterolateral third of the left forearm with skin loss, degloving injury of the thumb starting from the 1st metacarpal, exposure of the proximal two thirds of the 1st metacarpal bone, and both radial and ulnar digital arteries of the thumb damaged. A 10-cm-long vein graft was anastomosed in termino-later fashion between the dorsal branch of the radial artery and the uninjured distal part of the ulnar collateral digital artery of the thumb, successfully re-establishing its blood supply. Starting from the 1st postoperative day, the thumb was warm and pink while the other fingers were pale and capillary filling was absent. An urgent arteriography of the left upper extremity demonstrated the presence of normal radial artery, hypoplastic ulnar artery, dominant median artery, and absence of vascularization of the 2nd, 3rd, 4th, and 5th fingers. By the end of 2nd week, the patient underwent amputation of the four fingers at the distal metacarpal level. Anatomical anomalies of hand arterial blood supply are not uncommon, even though rarely reported in literature. Therefore, an instrumental study should be performed before attempting any arterial intervention even in emergency settings. Nevertheless, further studies should be performed to identify ready-to-use tools to make surgeons aware of any anatomic variations in order to avoid such complications.

Level of Evidence: Level V, therapeutic study.


Hand surgery Microsurgery Thumb replantation Surgical complication Ultrasound 



Authors would like to thank Marisa Mancini (O.U. of Hand Surgery and Microsurgery; Azienda Ospedaliero-Universitaria of Modena), medical and photograph illustrator, for her help in the making of the illustrations.

Compliance with ethical standards


This study did not receive any funding.

Conflict of interest

Norman Della Rosa, Nicolò Bertozzi, Giulia Colzani, and Roberto Adani declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Furthermore for this type of study formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Muzaffar AR, Chao JJ, Friedrich JB (2005) Posttraumatic thumb reconstruction. Plast Reconstr Surg 116:103e–122eCrossRefGoogle Scholar
  2. 2.
    Sharma S, Lin S, Panozzo A, Tepper R, Friedman D (2005) Thumb replantation: a retrospective review of 103 cases. Ann Plast Surg 55:352–356CrossRefGoogle Scholar
  3. 3.
    Landi A, Elliot D, Leti Acciaro A, Dellarosa N (2003) Linee guida di consenso sui reimpianti a livello dell’arto superiore. Paper presented at: Consensus Medicus, FidenzaGoogle Scholar
  4. 4.
    Rockwell WB, Haidenberg J, Foreman KB (2008) Thumb replantation using arterial conduit graft and dorsal vein transposition. Plast Reconstr Surg 122:840–843CrossRefGoogle Scholar
  5. 5.
    Adani R, Castagnetti C, Busa R, Caroli A (1995) Transfer of vessels in the management of thumb and ring avulsion injuries. Ann Acad Med Singap 24:51–57Google Scholar
  6. 6.
    Bilge O, Pinar Y, Ozer MA, Govsa F (2006) A morphometric study on the superficial palmar arch of the hand. Surg Radiol Anat 28:343–350CrossRefGoogle Scholar
  7. 7.
    Varley I, Carter LM, Wales CJ, Warnock N, Whitfield PH (2008) Ischemia of the hand after harvest of a radial forearm flap. Br J Oral Maxillofac Surg 46:403–405CrossRefGoogle Scholar
  8. 8.
    Filippini A, Zuccarini F, Trulli R, Aceto L, Serafini P, Rapani C, Gaspari AL, Guerra L, Passerini A, Calabrese B (1990) Venous grafts in reimplantation of the thumb. G Chir 11:545–550Google Scholar
  9. 9.
    Nystrom A, Backman C (1991) Replantation of the completely avulsed thumb using long arterial and venous grafts. J Hand Surg Br 16:389–391CrossRefGoogle Scholar
  10. 10.
    Vollala VR, Nagabhooshana S, Bhat SM, Rodrigues V, Rao M, Pamidi N, Surendran S (2008) Rare anatomical variant: arterial circle in palm and at the base of the thumb. Romanian J Morphol Embryol 49:585–587Google Scholar
  11. 11.
    Loukas M, Holdman D, Holdman S (2005) Anatomical variations of the superficial and deep palmar arches. Folia Morphol (Warsz) 64:78–83Google Scholar
  12. 12.
    Ozkus K, Pestelmaci T, Soyluoglu AI, Akkin SM, Ozkus HI (1998) Variations of the superficial palmar arch. Folia Morphol (Warsz) 57:251–255Google Scholar
  13. 13.
    Nayak SR, Krishnamurthy A, Ramanathan L, Prabhu LV (2008) The median-radial type of superficial palmar arch: a case report and review of the literature. Clinics 63:409–410Google Scholar
  14. 14.
    Heller F, Wei W, Wei FC (2004) Chronic arterial insufficiency of the hand with fingertip necrosis 1 year after harvesting a radial forearm free flap. Plast Reconstr Surg 114:728–731CrossRefGoogle Scholar
  15. 15.
    Holzle F, Kesting MR, Nolte D, Loeffelbein DJ, Swaid S, Wolff KD (2006) Reversible ischaemia after raising a radial forearm flap with ulceration of three fingers in a cigarette smoker. Br J Oral Maxillofac Surg 44:57–59CrossRefGoogle Scholar
  16. 16.
    Nunoo-Mensah J (1998) An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 66:929–931CrossRefGoogle Scholar
  17. 17.
    Agrifoglio M, Dainese L, Pasotti S, Galanti A, Cannata A, Roberto M, Parolari A, Biglioli P (2005) Preoperative assessment of the radial artery for coronary artery bypass grafting: is the clinical Allen test adequate? Ann Thorac Surg 79:570–572CrossRefGoogle Scholar
  18. 18.
    Yan ZX, Zhou YJ, Zhao YX, Zhou ZM, Yang SW, Wang ZJ (2010) Anatomical study of forearm arteries with ultrasound for percutaneous coronary procedures. Circ J 74:686–692CrossRefGoogle Scholar
  19. 19.
    Huzjan R, Brkljacic B, Delic-Brkljacic D, Biocina B, Sutli Z (2004) B-mode and color Doppler ultrasound of the forearm arteries in the preoperative screening prior to coronary artery bypass grafting. Coll Antropol 28:235–241Google Scholar
  20. 20.
    Vassilev D, Smilkova D, Gil R (2008) Ulnar artery as access site for car- diac catheterization: anatomical considerations. J Interv Cardiol 21:56–60CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Hand Surgery and MicrosurgeryAzienda Ospedaliero-Universitaria of ModenaModenaItaly

Personalised recommendations