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| Upper Extremity Arterial Disease- Debra Dice |
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Abstract
Arterial Diseases of Upper Extremity is uncommon and accounts for approximately 5% of cases of extremity ischemia; the remaining 95% of cases occur in the lower extremity. Ischemia in the upper extremity may be caused by a variety of systemic diseases such as Raynaud’s Syndrome, Arterial Occlusive Diseases, Aneurysms, Emboli, Trauma and Thoracic Outlet Syndrome. Thus, the diagnosis is often complex and requires a complete medical hx. as well as, physical examinations of location and extent of disease. Duplex scanning should be used to diagnosis disease. Treatment for upper extremity arterial disease is arterial surgery. |
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Key Words
Arterial Disease, Upper extremity disease, Arterial occlusive disease |
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Introduction
The normal arterial anatomy of the upper extremity begins at the aorta and extends to the digits of the hand. Thoracic Outlet and the arterial anatomy of the hand must be properly evaluated to correctly diagnosis diseases associated with abnormal anatomy of the arterial tree. Diseases of the upper extremity include Thoracic Outlet Syndrome, Atherosclerosis, Emboli, Subclavian Steel, Raynaud’s Disease, Aneurysms and Buerger’s Disease. These diseases can be diagnosed by using Duplex ultrasound with spectral doppler. Upper extremity arteries are imaged with a 3-5 MHz transducer for subclavian artery and 7.5-10 MHz for remaining superficial arteries with a linear probe. Wave forms in the upper extremity arteries are usually triphasic and scanning is performed similar to that of carotid or lower extremity arteries. Treatment almost always is surgery except for Buerger’s Disease which stop smoking is the best prevention and treatment for it. |
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Anatomy and Physiology
Normal anatomy of the upper extremity arteries originates from the aorta and extends to the Common Carotid Artery, Vertebral, Subclavian, Internal Mammary, Costocervical trunk, Axillary, Brachial, Radial, Ulnar and Palmar Arches of the hand to the digits. Many anatomic variants can occur in the arterial tree of the upper extremity and makes it confusing at times which leads to errors during duplex scanning, familiarity with these variants can prevent these types of problems. Collateral routes are sometimes used in response to disease or obstruction. The Subclavian artery leaves the chest via the thoracic outlet, where it passes over the first rib, behind the clavicle, and between anterior and middle scalene muscles. The Subclavian vein passes behind the clavicle, and anterior scalene muscle. The brachial plexus, which innervates the upper extremity, also exits from the thorax via the thoracic outlet between the anterior and middle scalene muscle. Because of the close confines of the thoracic outlet, the Subclavian artery, the Subclavian vein, and brachial plexus are subject to impingement and may generate upper extremity symptoms that are subject to evaluation by a vascular lab. Arterial anatomy of the hand consists of the radial and ulnar arteries crossing the wrist into the hand. There the Ulnar artery forms the superficial Palmar arch and the radial artery forms the deep Palmar arch. These arches are variable in size, origin, and anatomy. The common digital arteries usually arise from the superficial Palmar arch and divide into the proper digital arteries. The proper digital arteries travel along the medial and lateral sides of each digit and join at the tip of the digit. There are many diseases that occur in the upper extremity arterial system, such as Thoracic Outlet Syndrome, Atherosclerosis, Emboli, Subclavian Steel, Raynaud’s Disease, Aneurysms and Buerger’s Disease. |
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Atherosclerosis
Atherosclerosis is defined as hardening of arteries due to loss of elasticity of intimal and medial layers involving the upper extremity arteries. The larger arteries are usually involved, with lesions located proximally, particularly at the origins of the Subclavian and Innominate arteries. Atherosclerosis is most commonly found in upper extremity disease and two types are Arteriosclerosis obliterans which is 99% of cases in the West and Thromboangitis affects only 1% of disease involving large and medium-sized arteries. Plaque pathology is described as a fibrous plaque within intima, enlarges from subintimal position with smooth endothelial covering which breaks through vessel. Advanced plaque breaks down surface covering, with subsequent ulceration. Degenerating plaque contains fibrous tissue, fat, and calcium producing varying degrees of hemmorrhage. Duplex scanning can be used to diagnose stenosis and occlusion, as well as to evaluate collateral circulation patterns. Diagnosis of Atherosclerosis is Duplex scanning, Indirect noninvasive testing, Cold challenge Testing and Photoplethsmography. Treatment can be long term coumadin anticoagulation, surgery or resection of aneurysm. |
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Emboli
The major sources of Emboli to the arm and hand are proximal aneurysms and the heart. Emboli is defined as a thrombus or aneurysm occurring primarily from the heart which causes Pulmonary emboli. Signs and symptoms are shortness of breath, sudden feeling of apprehension, sharp chest pain, fainting sweating and a rapid pulse or increased breathing. Duplex scanning may be of use in patients with suspected emoblization to identify proximal aneurysms but primarily a lung perfusion scan performed in nuclear medicine or a chest x-ray. Treatment is anticoagulation or vena cava filters |
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Thoracic Outlet Syndrome
The Subclavian artery, Subclavian vein, and brachial plexus all pass through this small anatomic space that is bordered by the first rib, the clavicle, and the scalene muscles. Due to the multiple processes that may narrow the thoracic outlet this causes the term Thoracic Outlet Syndrome. Signs and symptoms in most patients are neck, shoulder, arm, and hand pain with immobility of limb along with tingling, numbness, and weakness of arm and hand. Symptoms can also be brought on by overhead activities such as combing hair or at night when sleeping on one side. Diagnosis is with MRI neurography, EMG’s or NCV’s which may show non-specific abnormalities, but may often be normal in patients with Thoracic Outlet Syndrome. Treatment is usually physical rehabilitation and surgery if no response to physical therapy. |
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Subclavian Steal
Subclavian steal Syndrome is defined as stenosis or obstruction of subclavian artery near its origin with flow reversal in ipsilateral vertebral artery decreasing cerebral circulation. It accounts for 2.5% of extracranial arterial occlusions in 40-60 year old with M:F ratio 3:1. Such a phenomenon may cause brainstem ischemia and stoke, either continuously or secondary to arm exercise. The primary lesion causing vertebral artery flow reversal is proximal Subclavian artery stenosis or occlusion, resulting in decreased blood pressure in the arm distal to the steno-occlusive disease. Signs and symptoms are dizziness, unsteadiness, vertigo, visual changes, arm ischemia causing arm claudication and rest pain. Diagnosis is x-ray, CAT scan, MRI, U/S by color doppler, MRA,and Angiography. Treatment is percutaneous trasluminal angioplasty or surgical revascularization |
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Raynaud's Disease
Raynaud’s Disease is an episodic digital ischmia in response to cold or emotional stimuli due to spasms of the digital arteries with color changes consisting of pallor(white), cyanosis( blue), and rubor(red). The two types are Occlusive-embolic and Vasospastic and with Raynaud’s Phenomenon there is secondary association with scleroderma, Arteriosclerosis, nerve injury, or trauma- blunt. Diagnosis is clinical presentation, cold intolerance testing, digital PPG, and digital B/P. Treatment is to avoid cold or stress and in severe cases surgery. |
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Aneurysms
Aneurysms are abnormal widening of the arterial wall promoting the formation of thrombus and tending to burst caused by arteriosclerosis. Signs and symptoms include pulsatile mass in upper extremity, artery is twice the normal size with distal embolization occuring with headaches, pain and inflammation of vessel. Diagnosis is duplex B-mode imaging evaluating size of enlarged artery, angiogram, CT and MRI. Treatment is arterial evacuation or surgery. |
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Buerger's Disease
Lastly is Buerger’s Disease is an inflammatory occlusive disease which involves all layers of medium and small arteries of the extremities. Majority of patients develop critical limp ischemia with lesions distal to ankle area as well as gangrene and ulceration. Males < 40 years old are primary candidates. Parasthesia, coldness and skin color changes may also be noted. The best treatment for this disease is to quit smoking. A physical exam and patient history are both sufficient to diagnosis Buerger’s Disease. Arteriogram is the gold standard for detecting arterial occlusive disease, duplex scanning is also useful to evaluate patient. |
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Conclusion
In conclusion, symptomatic upper extremity arterial occlusive disease is uncommon because of the abundant collateral network and low occurrence of atherosclerosis in upper extremity. Lesions are located @ origins of Subclavian and Brachiocephalic. Patients presenting with upper extremity ischemia range from young adults with nonatherosclerotic causes to elderly patients with atherosclerosis. Many patients with upper extremity arterial disease have associated Raynaud syndrome or significant cold sensitivity. Many non-invasive tests are used to diagnosis upper extremity disease such as duplex scanning, segmental arm pressures, digital pressure and PPG, Cold challenge test and Thoracic Outlet Syndrome testing with doppler. |
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Bibliography
Zweibel, William J., Introduction to Vascular Ultrasonography 4th Edition.
205-260 Philadelphia: W. B. Saunders Company., 2000
Yao, James, e Medicine Journal November 19 2001, Volume 2, Number 11
“Upper Extremity Occlusive Disease”
Curry, Reva Arnez and Tempkin, Betty Bates., Ultrasound: An Introduction to
Normal Structural and Functional Anatomy. 422-437 Philadelphia: W.B. Saunders Company., 1995
Thibodeau, Gary A., and Patton, Kevin T., The Human Body in Health and
Disease. 334-335, , 554 Wisconsin Mosby-Year Book, Inc., 1992
Ridgway, Donald P., Introduction to Vascular Scanning: A Guide for the
Complete Beginner 2nd Edition. 164-178 Pasadena: Davies Publishing Co.,
2001
Rumwell, Claudia and McPharlin, Michalene, Vascular Technology 2nd Edition.
2-5 California: Davies Publishing Inc. 2000
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Debra Dice Vas 135 17Sept. 2002
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Copyright CVTC 2003. All Rights Reserved.