Clinical Images  |   November 2018
Dry Digital Gangrene
Author Notes
  • From the Touro University College of Osteopathic Medicine–CA in Vallejo. 
  • Disclaimer: Dr Shubrook, an associate editor of The Journal of the American Osteopathic Association, was not involved in the editorial review or decision to publish this article. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Jay H. Shubrook, DO, 1310 Club Dr, Mare Island, Vallejo, CA 94592-1187. E-mail:
Article Information
Cardiovascular Disorders / Imaging / Hypertension/Kidney Disease / Clinical Images
Clinical Images   |   November 2018
Dry Digital Gangrene
The Journal of the American Osteopathic Association, November 2018, Vol. 118, 765. doi:
The Journal of the American Osteopathic Association, November 2018, Vol. 118, 765. doi:
A 61-year-old man presented to a clinic with the complaint of 6 weeks of right middle finger pain and swelling. His medical history included type 2 diabetes mellitus, hypertension, peripheral arterial occlusive disease, and chronic kidney disease. The patient received dialysis through an arteriovenous fistula in his right arm. The right middle finger became gangrenous after 8 weeks (image A). Postpresentation arteriogram records indicated steal syndrome causing vascular insufficiency in all right hand digits (image B). The right middle finger autoamputated a few weeks later. 
Hemodialysis is a common risk factor for ischemia of the upper extremity, and amputation is a common sequelae.1 Studies have shown that currently the best management of dialysis-associated steal syndrome is distal revascularization with interval ligation, which involves ligating an artery distal to the fistula and subsequently forming a bypass.2 Owing to the high mortality rates of dialysis patients who require upper extremity amputations, early revascularization efforts are key.3 
Ferraresi R, Acuña-Valerio J, Ferraris M, et al. Angiographic study of upper limb vascularization in a large cohort of hemodialysis patients with critical hand ischemia. Minerva Cardioangiol. 2016;64(6):642-647. [PubMed]
Regalado S, Navuluri R, Vikingstad E. Distal revascularization and interval ligation: a primer for the vascular and interventional radiologist. Semin Intervent Radiol. 2009;26(2):125-129. doi: 10.1055/s-0029-1222456 [CrossRef] [PubMed]
Stone AV, Xu NM, Patterson RW, Koman LA, Smith BP, Li Z. Five-year mortality for patients with end-stage renal disease who undergo upper extremity amputation. J Hand Surg Am. 2015;40(4):666-672. doi: 10.1016/j.jhsa.2014.12.036 [CrossRef] [PubMed]