Page 144 - Libro vascular I

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DUPLEX ASSESSMENT OF UPPER EXTREMITY ARTERIAL DISEASE
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Box 10.1 Common causes of symptoms involving the arterial and microvascular circulation of the arms and hands
● Atherosclerotic disease
● Acute obstruction due to emboli from the heart
● Aneurysms
● Fibrosis of the subclavian and axillary arteries
due to radiotherapy
● Shoulder and arm dislocation
● Trauma or stab wounds
● Damage caused by arterial access and invasive
blood pressure lines
● Thoracic outlet syndrome
● Raynaud’s phenomenon
● Reflex sympathetic dystrophy
● Vibration white finger disease
● Takayasu’s arteritis
Table 10.1 Anatomical variations of the upper limb arteries
Artery
Left subclavian artery
Brachial artery
Radial artery Ulnar artery
Variation
Common origin with common carotid artery from aortic arch
High bifurcation of brachial artery
High origin from axillary artery High origin from axillary artery
Table 10.2
upper arm
Diseased segment
Proximal subclavian artery
Distal subclavian or proximal axillary artery
Brachial artery
Radial and ulnar arteries
Major collateral pathways of the
Normal distal artery
Possible pathways
Vertebral artery, internal thoracic artery and thyro- cervical trunk
Collateral flow to the circumflex humeral arteries
Deep brachial artery to the recurrent radial and ulnar arteries
Interosseous artery and branches of the recurrent radial and ulnar arteries
Distal artery
Distal artery
subclavian
axillary
Distal artery radial arteries
brachial
or proximal and ulnar
Distal radial and ulnar arteries
or exercise. Patients with significant chronic symp- toms can be treated by angioplasty, provided that the lesion is suitable for dilation. Arterial bypass surgery is rarely performed in the upper extremi- ties. Acute obstructions can produce marked distal ischemia, and the forearm and hand may be cold and painful. In many cases of acute ischemia the condi- tion of the arm and hand improves with appropriate anticoagulation. However, embolectomy, throm- bolysis or bypass surgery may be performed if there is persistent distal ischemia. Trauma, due to injury or stab wounds to the arm or shoulder, can result in arterial damage, requiring local repair or bypass surgery. SA or axillary artery aneurysms can be bypassed with grafts, although in some cases a cov- ered stent can be deployed to exclude flow in the aneurysm sac. Occasionally, patients with arterio- venous fistulas will be encountered. These fistulas range in size and distribution and can affect the hand as well as the arm.
PRACTICAL CONSIDERATIONS FOR DUPLEX ASSESSMENT OF UPPER EXTREMITY ARTERIAL DISEASE
The objective of the scan is to identify and grade the severity of arterial disease in the upper limb
normally develop good collateral circulation around diseased segments. The major collateral pathways of the arm are summarized in Table 10.2.
SYMPTOMS AND TREATMENT OF UPPER
LIMB ARTERIAL DISEASE
The main causes of upper limb disorders are shown in Box 10.1. Many patients with chronic upper limb arterial disease experience few symptoms because of the development of good collateral circulation in the arm. However, some patients complain of aching and heaviness in the arm following a period of use