Raynaud’s Phenomenon-Associated Severe Hand Ischemia and Gangrene Salvaged with Concurrent Brachial–Radial–Ulnar Double Bypasses and A Multimodal Approach

INTRODUCTION: Raynaud's phenomenon (RP) is a vascular disorder characterized by episodic vasospastic attacks, often triggered by cold or stress. In vasospastic disorders such as RP, occurrences of gangrenous changes in the fingers are exceedingly rare. Standard treatments for RP include lifestyle adjustments and a variety of medication regimens, yet in severe cases involving digital ischemia and gangrene, RP management still remains without consensus. This report discusses a case of severe RP treated with a novel surgical approach after conventional therapies and surgical approaches failed.

CASE PRESENTATION: We describe a 47-year-old female with RP presenting with severe gangrene in the third finger. In this patient, medical management of RP, including initial treatments of lifestyle modifications and medications, failed to provide relief. When these conservative therapies proved ineffective, the decision was made to perform a brachial–radial–ulnar arterial thromboembolectomy. However, follow-up duplex ultrasounds showed velocities that were less than ideal despite the open radial and ulnar arteries, and the patient showed early signs of returning symptoms. Thus, the decision was made to perform a subsequent brachial–radial–ulnar double-bypass procedure, a unique surgical approach to RP. This surgical intervention successfully restored adequate perfusion, leading to complete recovery. Post-operatively, the patient demonstrated significant improvement, maintaining patent bypass and resuming normal activities supported by several years of a follow-up post-procedure.

DISCUSSION: This case highlights a complex RP presentation resistant to conventional therapies, necessitating surgical intervention. When thromboembolectomy was not sufficient, the dual-bypass strategy offered a unique solution by providing redundancy in blood supply, which was critical for hand function preservation. Yet, arterial bypasses remain infrequently documented in the literature as treatment options for RP, typically reserved for critical limb ischemia and other vascular diseases. This report emphasizes the importance of consideration for surgical bypass in managing severe RP, underscoring the need for individualized treatment strategies and tailored interventions in severe RP cases.