This is our data from the Mayo Clinic. I'd like to thank my co-authors as well as study coordinator. We have no financial disclosures. Hypothenar hammer is overall an uncommon cause of digital ischemia. The superficial nature of the ulnar arteries that passes through guillance places it at risk for trauma against the hook of the hammate. Can result in aneurysmal dilation or thrombosis. Not all are symptomatic, but when they are, medical therapy is the mainstay of treatment. Surgery is generally reserved for those that either fail medical therapy or have severe atrophic ulceration. No current randomized trials existed to find the most effective treatment. Historically, vascular reconstruction has been suggested for patients with a preoperative DBI of less than seven. Most of these are small case series that utilize vein graphs with patency rates reported anywhere from 57 to 100%. Currently, the longest mean follow-up reported has been just under five years. The purpose of our study was to evaluate the long-term patency rate and outcomes from vascular reconstruction of hypothenar hammer and see if we could identify any patient or treatment-related factors that may contribute to a difference in outcome that would help guide future therapy. So we identified all patients surgically treated at Mayo Clinic for hypothenar hammer from 94 to 2013, reviewed the operative reports to ensure that we had an accurate diagnosis and determined the nature of the reconstruction. We excluded everyone with less than a year follow-up pediatric patients, those with acute trauma or those with a known collagen vascular disorder that could potentially confound the results. We looked at their age at the time of operation, how long they had symptoms beforehand, any preoperative personal factors like smoking, presence of diabetes, whether or not they had any wounds. And then we also looked at the specific surgical details, including the type of reconstruction, the length of the graft used, if they had multiple distal anastomosis into the commons and any postoperative complications. At final follow-up, we had all patients perform a cold insensitivity survey, which is a six-question survey essentially to determine the impact of cold sensitivity, the duration of symptoms and how it impacts daily life. BAS for pain, we asked them to rate the result on zero to one, or excuse me, zero to 10 scale and then say whether or not they'd recommend it. I did an Allen's test and used a color flow Doppler to determine graft patency, which we defined as an identifiable flow through the graft without interruption. We also evaluated all the non-involved extremities as well. And this is just an example of a thrombosis. We used a standard statistical analysis using SAS. We identified 53 patients total that had hypothenar treated. Four patients were deceased at the time of study follow-up and one was less than a year out and excluded, yielding 48 eligible. I wasn't able to contact 23 and ultimately had 16 patients participate. 15 were male, one was female. 14 were unilateral disease and two were bilateral, yielding 18 total reconstructions. Three were active smokers, three had diabetes. In the meantime, between symptom onset and the operating room was just over a year. And as expected, the ring finger was the most commonly involved. A vein graft was used in each case. The mean length reconstructed was almost eight centimeters up to 13 centimeters and a branch distal anastomosis was used in seven cases. Our mean follow-up was 9.8 years. A vast majority of the grafts were occluded at follow-up 14 of 18 grafts. Four patients in the uninvolved arm had an occluded ulnar artery over an average length of 4.6 centimeters. And an Allen's test actually correlated really well with ultrasound findings in 31 of 32 vessels. Mean dash score was eight. CISS mean was 46, which puts it at a moderate. Patients graded it at an average of 7.5, anywhere from one to 10 in all 16 patients recommended it, even the person that rated it a one. Independent variable analysis, the gist of this slide is essentially we didn't identify a single factor, be it length of recon, whether or not they were smoker, if they were distal branches, et cetera, that predicted graft occlusion. There was a significant improvement in cold sensitivity and significantly better cold sensitivity scores in those with patent grafts at final follow-up versus those with occluded grafts. Patent 21.8 is mild and 55 is severe. Visual analog scale for pain was significantly different, although clinically not likely relevant given it was so low. Patients graded it significantly better in those with patent reconstructions at 9.5 versus 6.8. And dash scores and grip strength were not significantly different between the two groups. Our limitations are that we have a small sample size. It was retrospective in nature with an overall low capture rate, and we also didn't have any pre-treatment self-reported outcome scores for comparison. So in conclusion, the study demonstrates a higher rate of graft occlusion than previously reported. I do know that there was time intervals where there were patent grafts on surveillance imaging that later occluded after the five-year follow-up, so late occlusions were definitely a part of the study. Long-term patency resulted in significantly less pain and cold sensitivity compared to patients with occluded grafts, suggesting that patent grafts are important for outcome. And then patient with patent grafts had improved self-reported scores. Overall, patients were very satisfied in both groups with low functional disability. Thank you. Thank you. Thank you. The authors have presented an insightful and sobering study regarding the long-term outcomes for a surgical problem that most of us will see and operate on rather infrequently. I have two questions. One, my initial response on reading the paper, given the very high rate of late thrombosis of the vein grafts, was that, in my practice, I would consider shifting to lifelong anticoagulation like many of our vascular medicine and surgical colleagues do for similar problems. But your data, as I look at it, doesn't really support that. So my first question is, what are the authors doing in terms of anticoagulation and length of anticoagulation? And my second question is that, given the clinical success, even in patients whose vein grafts failed late, do the authors think there is some benefit to the increased perfusion over an intermediate time period, or is the clinical success simply due to the necessary sympathectomy at the surgery? So for the first question, we put the patients on aspirin generally post-op initially for about 30 days to just allow for the time for re-epithelialization of the vessels, which the 30 days is sort of voodoo. There's no data to support that, but that's the current practice. The second question, I think the sympathectomy has a significant role in the treatment, and I think that having a patent graft, at least for a period of time, can allow for that collateral circulation to develop and potentially alleviate symptoms longer term. So I think the fact that patients with a patent graft ultimately had less cold sensitivity does suggest that there is some importance in having long-term flow through that graft. Thank you.

vascular reconstruction

hypothenar hammer

digital ischemia

patency rates

outcomes