Upper-Extremity Arterial Occlusive Disease Workup

Updated: Sep 20, 2022
  • Author: Mark K Eskandari, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Workup

Laboratory Studies

In patients with Raynaud syndrome who may have systemic vasculitis or underlying connective-tissue disease, the following tests should be obtained:

  • Erythrocyte sedimentation rate (ESR) - 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 (RA)

In selected patients, obtain a hypercoagulability workup. Molecular tests of hypercoagulability include the following:

Additional tests include the following:

  • Complete blood count (CBC) and platelet count
  • Urinalysis
  • In selected patients, cryoglobulins, cold agglutinins, and serum protein electrophoresis
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Imaging Studies

Complete arteriography of both upper extremities is necessary to establish the diagnosis and plan effective treatment. The arteries to the upper extremity must be clearly visualized, beginning with the arch and extending to the digits (see the images below). Magnification produces detailed studies of the hand.

Arteriogram of aortic arch demonstrating (1) brach Arteriogram of aortic arch demonstrating (1) brachiocephalic vessel, (2) right subclavian, (3) right carotid, (4) left carotid, and (5) left subclavian. These are normal findings.
Brachial segment demonstrating high takeoff of rad Brachial segment demonstrating high takeoff of radial artery from mid brachial artery.
Forearm vessels in patient with distal embolizatio Forearm vessels in patient with distal embolization, including (1) radial artery, (2) interosseous artery, and (3) ulnar artery. (Ulnar artery demonstrates distal occlusion.)
Distal ulnar artery occlusion and proximal radial Distal ulnar artery occlusion and proximal radial artery occlusion with obliteration of superficial palmar arch from distal embolization.
Digital subtraction angiogram demonstrating normal Digital subtraction angiogram demonstrating normal subclavian axillary brachial segment with arm at patient's side.
Angiogram of upper extremity. Top is in normal pos Angiogram of upper extremity. Top is in normal position; bottom is in hyperabducted position (arrow indicates area of stenosis).

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 the image below).

Chest radiography and cervical spine views reveal a cervical rib or abnormality of the first rib in patients with thoracic outlet syndrome. Alternatively, computed tomography (CT) with three-dimensional reconstruction can be used.

The 2017 guidelines from the European Society of Cardiology (ESC) and the European Society of Vascular Surgery (ESVS) noted that CT angiography (CTA) is an excellent imaging tool for supra-aortic lesions and that magnetic resonance angiography (MRA) provides functional and morphologic information useful for distinguishing anterograde from retrograde perfusion and estimating stenosis severity. [5]

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 to determine the presence of a right-to-left shunt through which paradoxical emboli might travel.

Hand radiographs reveal calcinosis and tuft resorption.

In a prospective pilot study, Sumpio et al evaluated the use of hyperspectral imaging (HSI), a technology that noninvasively measures oxygenated hemoglobin and deoxygenated hemoglobin concentrations in the skin, for demonstrating upper-extremity vascular dysfunction in patients with peripheral artery disease (PAD) and coronary artery disease (CAD). [6] The study results suggested that HSI may be able to detect PAD or CAD on the basis of remote systemic vascular dysfunction at sites, thereby enabling early screening and tracking of arterial disease before it becomes clinically advanced.

Indocyanine green fluorescent imaging has been described as a noninvasive means of characterizing and quantifying microcirculatory disorders in patients with peripheral arterial occlusive disease of the upper extremity. [7]

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Procedures

Noninvasive laboratory studies include bilateral upper-extremity arm, forearm, and digital blood pressures.

Doppler arterial waveforms are taken at the subclavian, axillary, brachial, ulnar, and radial arteries and the palmar arch. A triphasic waveform (see the image below) denotes normal arterial blood flow. Duplex scanning with Doppler spectral analysis and B-mode ultrasonography (US) provides a detailed anatomy of the subclavian, axillary, and brachial arteries.

Normal results on right upper extremity Doppler ex 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.

In a retrospective analysis that evaluated the sensitivity and specificity of laser Doppler flowmetry (LDF) measurements for digital obstructive arterial disease (DOAD) against the reference standard of angiography, Mahe et al found that LDF combined with thermal challenge was an accurate, safe, and noninvasive method of detecting DOAD. [8]

Photoplethysmography (PPG) is used to monitor arterial blood flow to the fingers during the Adson maneuver and provides objective evidence of arterial occlusion. In a study that included 24 patients with end-stage renal disease, Briche et al found LDF to be superior to PPG for characterizing PAD of the upper extremities. [9]

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.

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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.

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