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Vascular Surgery > MEDICAL TOPICS
Upper Extremity Occlusive Disease
Article Last Updated: Apr 5, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Mark K Eskandari is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, International Society of Endovascular Specialists, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Interventional Radiology, Society of University Surgeons, and Western Surgical Association
Coauthor(s):
James S T Yao, MD, PhD, Emeritus Professor of Surgery, Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine;
William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
Editors: Jeffrey Lawrence Kaufman, MD, Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
upper extremity occlusive disease, upper extremity arterial disease, atherosclerosis, arteritis, fibromuscular dysplasia, Raynaud syndrome, cold sensitivity, Raynaud disease, subclavian artery stenosis, Takayasu arteritis, subclavian artery disease, acute arterial occlusion, brachial artery occlusion, digital gangrene, Buerger disease, fibromuscular dysplasia, digital artery occlusion, scleroderma, chondrocalcinosis, esophageal motility disorder, sclerodactyly, telangiectasia, CREST syndrome, mixed connective-tissue disease, hypersensitivity angitis, hypothenar hammer syndrome
History of the Procedure
Symptomatic upper extremity arterial occlusive disease is uncommon because of the abundant collateral network and the infrequency of atherosclerosis in the upper extremity. Patients who present with upper extremity ischemia range from young adults with nonatherosclerotic causes to elderly patients with atherosclerosis.
Problem
Arterial occlusive disease of the upper extremity may represent either local or systemic disease. The pattern of arterial disease varies according to etiology. Diseases that affect the brachiocephalic vessels include atherosclerosis, arteritis, congenital anomalies, trauma, and fibromuscular dysplasia. In the United States, atherosclerosis is the most common cause of subclavian artery stenosis. Outside of the United States, Takayasu arteritis is more common. The axillary and brachial arteries are common sites of injury. One third of peripheral emboli lodge in the upper extremity, producing acute arterial occlusion. Radiation therapy of the chest or breast may induce subclavian artery disease.
Frequency
Brachial artery occlusion occurs in 0.9-4% of cardiac catheterizations. The brachial artery is also the most commonly injured artery in civilian trauma (30% of all arterial injuries). Digital gangrene is a frequent manifestation of connective-tissue disease or a hypercoagulable state. Buerger disease manifests with multiple digital artery occlusions caused by heavy smoking and is rare. Many patients with upper extremity arterial disease have associated Raynaud syndrome or significant cold sensitivity.
Etiology
- Large-vessel occlusion (eg, subclavian, brachial, forearm arteries)
- Atherosclerosis
- Trauma (eg, thoracic outlet syndrome, penetrating, blunt, iatrogenic)
- Arteritis (eg, Takayasu arteritis, giant cell)
- Irradiation
- Embolic (eg, cardiac or thoracic outlet in origin, including bacterial endocarditis, microemboli from ascending aorta, paradoxical emboli)
- Fibromuscular dysplasia
- Digital artery occlusion (see Image 1)
- Connective-tissue disease - Scleroderma; chondrocalcinosis, Raynaud phenomenon, esophageal motility disorder, sclerodactyly, and telangiectasia (CREST); and mixed connective-tissue disease
- Buerger disease
- Hypersensitivity angitis
- Hematologic - Hypercoagulable states, hyperviscosity, malignancy
- Traumatic - Occupational (eg, hypothenar hammer syndrome, vibratory tools), iatrogenic, recreational (baseball palmar artery injuries)
- Infection - Infection from injection of drugs, infection from arterial procedures
- Flow phenomenon - Vascular steal related to dialysis access graft or fistula placement
Pathophysiology
Vasculitis, fibromuscular dysplasia, and atherosclerosis produce symptoms related to progressive narrowing of the arterial lumen. A diameter reduction of 50% or a cross-sectional area reduction of 70% represents a hemodynamically significant lesion. These lesions produce a pressure drop across the stenotic area. The distal arterial bed is supplied by collateral blood vessels. Symptoms include exercise-induced fatigue as the demand for blood exceeds the supply. In patients with acute arterial occlusions, collateral blood vessels have not formed, and perfusion drops rapidly below a critical threshold level, which results in persistent pain and tissue necrosis. Limb pressure is generally less than 30 mm Hg. Doppler tones cannot be heard in the digital vessels. The pathophysiology of Raynaud syndrome is unknown. Precapillary smooth muscle cells constrict in an abnormal response to cold stimulation. The sympathetic nervous system adrenoreceptor function and number are believed to be altered. The distinction between Raynaud disease and Raynaud phenomenon is arbitrary and is best divided into patients with normal digital arteries (Raynaud disease) and patients with obstructed arteries (Raynaud phenomenon). The two are easily distinguished using noninvasive blood flow testing (see Diagnostic Procedures).
Clinical
- The patient’s history may include the following:
- Arm fatigue upon exercise (ie, subclavian artery occlusion)
- Vertebrobasilar insufficiency (ie, subclavian steal)
- Rest pain that involves hand and digits
- Digital gangrene
- Raynaud syndrome (eg, color changes—white, blue, red or white, red, blue)
- Smoking history
- Occupational and recreational history (eg, baseball pitcher, tennis player, handballer, carpenter)
- Drug ergots (peripheral vasoconstrictors used in the treatment of shock [eg, dopamine, adrenaline])
- The results of physical examination include the following:
- Fever (if an associated vasculitis is present)
- Unequal arm pressures (>20 mm Hg difference)
- Supraclavicular or infraclavicular bruit
- Adson maneuver (loss of radial pulse upon abduction and external rotation of the upper extremity)
- Supraclavicular pulsatile mass (associated with a subclavian aneurysm or cervical rib)
- Palpation of pulses (axillary, brachial, radial, ulnar)
- Digital gangrene
- Color and capillary refill of the digits
- A positive Allen test result: An abnormal result on the Allen test demonstrates an incomplete palmar arch. In this test, the ulnar and radial arteries are occluded with the fist clenched. The hand is then opened, releasing one of the arterial occlusions (radial or ulnar); prompt capillary refill should result. The same maneuver should then be performed with the release of the other artery. If the palmar arch is not intact, the release of the affected artery produces a sluggish capillary refill. Alternatively, a Doppler stethoscope is used to map these collateral flow patterns in the hand by manually occluding, one at a time, the radial and ulnar arteries.
- Arm fatigue - Carotid-subclavian bypass (see Image 2), percutaneous transluminal angioplasty (PTLA), and stent
- Vertebrobasilar insufficiency - Carotid subclavian bypass and possible vertebral artery transposition to carotid artery
- Subclavian aneurysm and thoracic outlet injuries with distal embolization - Resection of subclavian artery aneurysm and venous bypass and rib resection with thoracic outlet (see Image 3)
- Acute arterial occlusion - Embolectomy for embolus and repair for trauma (blunt or penetrating)
- Chronic arterial occlusion with pain at rest, ulcer, or gangrene - Bypass using the autogenous vein for distal segments and prosthetic material for larger proximal segments, amputation (digital or forearm), and sympathectomy (controversial)
See Image 4. Right subclavian artery: This artery originates from the innominate artery. Rarely, the origin of the right subclavian is distal to the left subclavian, passing behind the esophagus and producing dysphagia lusoria (ie, difficulty swallowing). An aberrant right subclavian artery is also prone to aneurysm degeneration (ie, Kommerell diverticulum). Vertebral artery: This is the first branch of the subclavian and a major collateral for proximal subclavian artery stenosis (retrograde vertebral artery blood flow). The distal vertebral artery also provides blood flow to the anterior spinal artery. Internal mammary artery: The internal mammary artery (IMA) is the second branch of the subclavian artery and is used for coronary artery bypass grafting (CABG). Occasionally, progressive subclavian stenosis produces angina in patients who have undergone CABG. Brachial artery: This branches at the elbow into the ulnar, radial, and interosseous arteries. Rarely, the ulnar and radial arteries arise from the axillary or subclavian arteries. Ulnar and radial arteries: These connect in the hand to form the superficial and deep palmar arches. Palmar arch anatomy varies. In most patients, the ulnar artery is the dominant blood supply of the hand.
Few contraindications for surgical intervention exist in the presence of significant cerebrovascular symptoms or gangrene of the hand. Arterial reconstruction may not be feasible if too many of the outflow target arteries are destroyed. Asymptomatic subclavian artery stenosis, even with radiographic evidence of subclavian steal (retrograde vertebral flow), should not be treated. Severe coexisting life-threatening illness may prevent surgical intervention.
Lab Studies
- In patients with Raynaud syndrome who may have systemic vasculitis or underlying connective-tissue disease, the following tests should be obtained:
- Sedimentation rate - To detect systemic inflammation or vasculitis
- Antinuclear antibodies (ANA) - To test for serology of systemic lupus erythematosus (SLE)
- Rheumatoid factor (RF) - To test for serology of rheumatoid arthritis
- In selected patients, obtain a hypercoagulable workup. Molecular tests of hypercoagulability include the following:
- Factor V Leiden mutation
- Prothrombin 20210 gene mutation
- Methyl tetrahydrofolate reductase (MTHFR) (homozygote)
- Factor V (heterozygote)
- Antithrombin III deficiency
- Protein C deficiency
- Protein S deficiency
- Dysfibrinogenemia
- Antiphospholipid antibodies
- Hyperhomocysteinemia
- Elevated lipoprotein (a)
- Platelets
- CBC count, platelet count, and urinalysis
- Cryoglobulins, cold agglutinins, and serum protein electrophoresis in selected patients
Imaging Studies
- Complete arteriography of both upper extremities is necessary to establish the diagnosis and plan an effective treatment.
- The arteries to the upper extremity must be clearly visualized, beginning with the arch and extending to the digits. Magnification produces detailed studies of the hand (see Images 6-9).
- Intra-arterial vasodilation often provides a detailed anatomy of the hand.
- The arm should be placed in the abducted externally rotated position to determine arterial occlusion produced by thoracic outlet structures (see Image 10).
- Chest radiography and cervical spine views reveal a cervical rib or abnormality of the first rib in patients with thoracic outlet syndrome. Alternatively, CT imaging with 3-dimensional reconstruction can be used.
- Transesophageal echocardiography (TEE) is performed in patients with a peripheral embolus suspected of originating from a cardiac source. TEE can be used to assess plaque in the ascending aorta as a source of the emboli or determine the presence of a right-to-left shunt through which paradoxical emboli might travel.
- Hand radiographs reveal calcinosis and tuft resorption.
Diagnostic Procedures
- Noninvasive laboratory studies (see Image 5) include bilateral upper extremity arm, forearm, and digital blood pressures.
- Doppler arterial waveforms are taken at the subclavian, axillary, brachial, ulnar, radial, and palmar arch. A triphasic waveform denotes normal arterial blood flow.
- Duplex scanning with Doppler spectral analysis and B-mode ultrasound scan provides a detailed anatomy of the subclavian, axillary, and brachial arteries.
- Photoplethysmography (PPG) is used to monitor arterial blood flow to the fingers during the Adson maneuver and provides objective evidence of arterial occlusion.
- The cold stimulation test is painful and rarely needed. A baseline temperature is recorded with a small digital thermistor. The hand is immersed in ice water for 20 seconds. The time to return to baseline temperature is normally 15 minutes. In patients with vasospastic disease, the recovery time is prolonged.
Histologic Findings
In patients with clinical findings and angiography findings consistent with giant cell arteritis, obtaining a biopsy of the affected arteries is usually impossible without risking the destruction of collateral vessels around the occlusion. Because this disease can affect other beds, results from a temporal artery biopsy may be abnormal.
Medical therapy
- Long-term warfarin anticoagulation is recommended in patients with peripheral emboli from a cardiac source. An international normalized ratio (INR) of 2-3 is recommended.
- For emboli off the ascending aorta, aspirin or clopidogrel may be used. In rare cases, low-dose aspirin has been used with warfarin.
- Nifedipine (10 mg PO tid) is used in patients with vasospastic disease of the hand. If this is not tolerated, prazosin at low dose may be tried. A third-line drug with some effectiveness is hydralazine.
- Lifestyle changes are essential. Warm gloves must be worn, and the skin must be protected from drying and fissuring. Cold avoidance may require moving to a warm climate and avoidance of significantly chilled or air-conditioned environments. Avoidance of vibration trauma from work or hobbies may be necessary.
- In patients with Takayasu arteritis or giant cell arteritis, prednisone is the first-line agent. Immunosuppression with methotrexate or Cyclophosphamide (Cytoxan) may be necessary.
- Risk-factor modification and aspirin are essential for the treatment of atherosclerotic occlusion. Smoking cessation is mandatory, particularly in patients with Buerger syndrome. Total cholesterol levels should be reduced to below 200 mg/dL, and the low-density lipoproteins (LDL) levels should be 100 mg/dL or less.
Surgical therapy
- Vein or prosthetic bypass
- Percutaneous balloon angioplasty and stenting
- Resection of aneurysm
- Removal of first rib or cervical rib
- Cervical sympathectomy
Preoperative details
- Standard preanesthesia evaluation of a chest radiograph (if patient has chest symptoms), ECG, cardiac evaluation (if cardiac history or examination findings are abnormal), CBC count, and chemistry panel
- Prophylactic antibiotics
- Ultrasound mapping to delineate available saphenous or other veins to be used for bypass
Intraoperative details
- Carotid subclavian or carotid transposition: Incision is low transverse cervical. Prosthetic bypass is preferred. Complications include lymphocele, Horner syndrome, and phrenic nerve injury.
- Balloon angioplasty and stenting: These are used via either a retrograde or antegrade approach.
- Subclavian artery aneurysm resection and removal of cervical rib for thoracic outlet: Incisions are supraclavicular and infraclavicular. Avoid brachial plexus injury. Rib resection is facilitated following division of the artery. Management of distal emboli is difficult. Complications include lymphocele, Horner syndrome, and phrenic nerve injury.
- Peripheral artery surgery: For the axillary artery, exposure is through a longitudinal incision. Ulnar, median, and musculocutaneous nerve injuries are possible.
- Brachial artery: It is exposed through an S incision. Median nerve injury is possible.
- Embolectomy: Embolectomy should be avoided over distension of balloon catheter. Patch brachial and small axillary arteries.
Postoperative details
- Monitor distal circulation with frequent pulse examination, with or without Doppler pressures.
- Monitor for bleeding and hematoma formation.
- Document neurologic function by testing median, ulnar, and radial nerve function.
- Be aware that forearm compartment syndrome can occur.
- Monitor ECG to rule out perioperative myocardial infarction or ischemia.
Follow-up
The patient is seen at 2 weeks for wound check, suture removal, or both. Repeat upper extremity blood flow tests are performed every 3 months for the first year, then annually thereafter. Review the patient's control of risk factors, including smoking.
- Bleeding (1%)
- Hematoma (1%)
- Phrenic or recurrent nerve injury (2%)
- Graft occlusion (1-2%)
- Wound infection (1%)
- Brachial plexus or peripheral nerve injury (1%)
- Myocardial infarction (<1%)
- Stroke (<1%)
- Death (<1%)
- Carotid-subclavian bypass yields 86-100% 5-year patency.
- Subclavian transposition yields 95-100% 5-year patency.
- Upper extremity bypass yields 52% 5-year patency.
- Arterial reconstruction for thoracic outlet yields 90% 5-year patency.
- Zero to 25% of patients with Raynaud disease with negative serology findings develop a connective-tissue disease, and 11-60% of patients with Raynaud disease with positive serology findings develop a connective-tissue disease.
Percutaneous transluminal angioplasty (PTLA), with or without stenting, is used to treat proximal subclavian stenosis. The indications for PTLA of subclavian artery stenosis include vertebrobasilar insufficiency with steal, angina with left internal mammary artery (LIMA) graft, and arm fatigue. The role of a thoracic or digital artery sympathectomy is controversial in patients with digital gangrene. These patients usually have an underlying connective-tissue disease such as scleroderma; calcinosis, cutis, Raynaud phenomenon, esophageal motility disorder, sclerodactyly, and telangiectasia (components of CREST); or systemic lupus erythematosus (SLE). Either thoracic or digital sympathectomy provides a transient 6-12 months of increased skin perfusion.
| Media file 1:
Photograph that demonstrates digital ischemia in a patient with long-standing diabetes mellitus who is on long-term dialysis. |
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Anatomic drawing of the subclavian and brachial arteries. |
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An arteriogram of the aortic arch that demonstrates the (1) brachiocephalic vessel, (2) the right subclavian, (3) the right carotid, (4) the left carotid, and (5) the left subclavian. These are normal findings. |
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Brachial segment that demonstrates a high take-off of the radial artery from the mid brachial artery. |
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| Media file 7:
Forearm vessels in a patient with distal embolization that demonstrate (1) radial artery, (2) interosseous artery, and (3) ulnar artery. (The ulnar artery demonstrates distal occlusion.) |
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Distal ulnar artery occlusion and proximal radial artery occlusion with obliteration of the superficial palmar arch from distal embolization. |
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Normal results on right upper extremity Doppler examination demonstrate triphasic waveform and wrist/brachial index of 0.63. Left upper extremity demonstrates axillary, brachial, and palmar artery disease. |
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| Media file 10:
Digital subtraction angiogram that demonstrates a normal subclavian axillary brachial segment with the arm at the patient's side. |
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Angiogram of upper extremity. The top is in a normal position. The bottom is in a hyperabducted position (arrow indicates area of stenosis). |
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- Dennis JW, Frykberg ER, Crump JM. New perspectives on the management of penetrating trauma in proximity to major limb arteries. J Vasc Surg. Jan 1990;11(1):84-92; discussion 92-3. [Medline].
- Durham JR, Yao JS, Pearce WH. Arterial injuries in the thoracic outlet syndrome. J Vasc Surg. Jan 1995;21(1):57-69; discussion 70. [Medline].
- Eskandari MK, Yao JST. Occupational Vascular Problems. In: Rutherford RB, ed. Vascular Surgery, 6th ed. Philadelphia, Pa:. WB Saunders;2005, in press.
- Halpin DP, Moran KT, Jewell ER. Arm ischemia secondary to giant cell arteritis. Ann Vasc Surg. - Moran KT;2(4):381-4. [Medline].
- Kaar G, Broe PJ, Bouchier-Hayes DJ. Upper limb emboli. A review of 55 patients managed surgically. J Cardiovasc Surg (Torino). Mar-Apr 1989;30(2):165-8. [Medline].
- Kline RM Jr, Hertzer NR, Beven EG. Surgical treatment of brachial artery injuries after cardiac catheterization. J Vasc Surg. Jul 1990;12(1):20-4. [Medline].
- Landry GJ, Edwards JM, McLafferty RB. Long-term outcome of Raynaud''s syndrome in a prospectively analyzed patient cohort. J Vasc Surg. Jan 1996;23(1):76-85; discussion 85-6. [Medline].
- McCroskey BL, Moore EE, Pearce WH. Traumatic injuries of the brachial artery. Am J Surg. Dec 1988;156(6):553-5. [Medline].
- Mesh CL, McCarthy WJ, Pearce WH. Upper extremity bypass grafting. A 15-year experience. Arch Surg. Jul 1993;128(7):795-801; discussion 801-2. [Medline].
- Nomura M, Kida S, Yamashima T. Percutaneous transluminal angioplasty and stent placement for subclavian and brachiocephalic artery stenosis in aortitis syndrome. Cardiovasc Intervent Radiol. Sep-Oct 1999;22(5):427-32. [Medline].
- Peterson BG, Resnick SA, Morasch MD. Aortic arch vessel stenting: a single-center experience using cerebral protection. Arch Surg. 2006;141:560-564.
- Peterson BG, Resnick SA, Morasch MD. Aortic arch vessel stenting: a single-center experience using cerebral protection. Arch Surg. 2006;141:560-564.
- Phipp LH, Scott DJ, Kessel D. Subclavian stents and stent-grafts: cause for concern?. J Endovasc Surg. Aug 1999;6(3):223-6. [Medline].
- Rodriguez-Lopez JA, Werner A, Martinez R. Stenting for atherosclerotic occlusive disease of the subclavian artery. Ann Vasc Surg. May 1999;13(3):254-60. [Medline].
- Safran MR, Bernstein A, Lesavoy MA. Forearm compartment syndrome following brachial arterial puncture in uremia. Ann Plast Surg. May 1994;32(5):535-8. [Medline].
- Yao JST, Flinn WR, McCarthy WJ. Upper extremity revascularization. In: Bergan JJ, Yao JST. Techniques in Arterial Surgery. Philadelphia, Pa:. WB Saunders, Co;1990:328-336.
- Ziomek S, Quinones-Baldrich WJ, Busuttil RW. The superiority of synthetic arterial grafts over autologous veins in carotid-subclavian bypass. J Vasc Surg. Jan 1986;3(1):140-5. [Medline].
Upper Extremity Occlusive Disease excerpt Article Last Updated: Apr 5, 2007
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