The initial workup of the patient suspected of having significant upper-extremity arterial disease starts as always with a history and physical. Because of the multiple differing pathologic conditions that can be involved in upper-extremity disease as opposed to the more predictable causes of lower-extremity disease, the history and physical must inherently be a more complete history and physical as opposed to the focused workup that a patient suspected of having lower-extremity atherosclerosis might undergo. In the history, the duration and the nature of the symptoms and their speed of onset should be noted. Often people who have had embolic or microembolic events can directly relate a specific sudden moment at which time their symptoms began. The presence or absence of Raynaud symptoms obviously should be noted, especially whether they have been present for a long time and have simply worsened slowly or if they have been of recent onset and if there are any exacerbating factors. A complete and thorough past medical history should be taken, looking specifically for obvious problems such as risk factors for cardiovascular and atherosclerotic disease, renal failure, and the like, but also focusing on the presence or absence of conditions suggestive of connective tissue disorders— problems with swallowing suggestive of scleroderma, arthritic-type symptoms, and a history of rashes or other cutaneous manifestations of diseases, such as systemic lupus erythematosus (SLE). In addition, diseases of the upper extremity seem to be more frequently associated with coagulation problems, and a full and careful history detailing bleeding patterns including menstrual difficulties or unusual bleeding or clotting associated with other surgical procedures in the past should be noted. A review of the family history for coagulation disorders is also useful and mandatory in these situations.

A history of previous trauma or environmental exposure should be elicited in great detail. Patients with a history of frostbite might forget to volunteer this information without being directly questioned about this matter. Similarly, hypothenar hammer syndrome is very often associated with a work-related or lifestyle-related source of trauma that is not immediately apparent to the patient and would not necessarily be spontaneously volunteered. In our experience, it is more likely that the patient had an occupational reason to use the hypothenar eminence as a hammer, as opposed to the typical picture of possibly a karate aficionado causing damage to his ulnar artery.

Other types of iatrogenic injury might play a part in the genesis of upper-extremity occlusive disease. Previous cardiac catheterizations involving the brachial artery are a frequent source of occlusion at this level that might have escaped initial notice and only with the passing of time would become clinically evident. Similarly, pointed questions should be made regarding trauma, such as a motor vehicle accident; even something resembling a minor “fender bender” might lead to damage to the anterior scalene muscle and the subsequent onset of thoracic outlet-type symptoms.

The patient’s medication list should be closely examined both in the sense that this can give the clinician several hints as to possible risk factors or associated medical diseases that might be tied to the patient’s symptomatology. Certain medications, such as beta-blockers, may sometimes aggravate upper-extremity symptoms without the patient’s awareness. In addition, intra-arterial injection of medications, such as alphaadrenergic agents or cocaine, may lead to digital vessel occlusion and chronic pain symptomatology.

The physical examination should involve palpation of the axillary, brachial, radial, and ulnar pulses. An Allen test should commonly be performed. On the other hand, we find the Adson test to be nonspecific and is not routinely done. The presence of finger cyanosis or discoloration as well as tenderness should be noted. Ulceration or frank gangrene should obviously be recorded. Inspection of the arm might reveal the presence of previous punctures or incisions for cardiac catheterization at the brachial artery, arterial line catheterization at the radial artery, or previous anteriovenous access procedures
for renal failure, all of which may play a part in the patient’s complaints.

Patients with significant digital ischemia might also demonstrate decreased sensory function, paresthesias, or dysesthesias. These symptoms should be differentiated from primary neurologic problems. Examination of the thoracic outlet, the median nerve at the wrist, and the ulnar nerve at the elbow should be performed.

It should be noted, in particular, whether the symptoms are unilateral or bilateral. Bilaterality might more frequently suggest a systemic problem, such as scleroderma, whereas a unilateral problem might direct the physician to look for an embolic source.

Unless the history and physical clearly suggest the diagnosis, these patients should undergo a battery of laboratory tests that look for evidence of connective tissue disease and coagulation. Table 35-1 lists some suggested blood tests that may be obtained. Table 35-2 lists studies that would be obtained if there is a suggestion of coagulopathy. An electrocardiogram is useful in determining and demonstrating the heart rhythm, and chest and neck films are useful in evaluating the presence of cervical ribs. Occasionally calcification in a subclavian or innominate aneurysm might be evident on these films as well. Almost uniformly, these patients undergo vascular laboratory studies that include plethysmography of the arms and the fingers. Segmental pressures are obtained simultaneously. As has been suggested by Nielsen et al., the response of the digital pulse volume recordings (PVRs) to reactive hyperemia is sometimes more useful to clearly delineate non-invasively the presence of significant occlusive disease. As a secondary study we often employ duplex ultrasonography of the axillary, brachial, and forearm arteries. This is sometimes a useful noninvasive method of evaluating suspected lesions detected at the time of the first visit by either history and physical examination or PVRs.

In patients with either significant tissue loss, studies suggestive of a more proximal source of occlusive disease, or the upper-extremity equivalent of claudication (exertional pain in the arm related to occlusive disease that the patient finds unsatisfactory or not tolerable), angiography should be performed. Magnetic resonance angiography (MRA) is often obtained, but we have found this to be of questionable use with demonstration of lesions in the axillosubclavian segments that do not exist. Conversely, this test is often not sensitive enough to delineate occlusive disease in the distal radial, ulnar, or palmar arteries. Conventional contrast arteriography is preferred for both definitive diagnosis and for pre-operative planning. In the patient with unilateral symptoms suggestive of embolic disease, biplanar views should be obtained of the arteries on the involved side starting from the aortic arch. Despite this, patients still may have a source for atheroembolism that may not be evident with arteriography, as the embolic site may simply be too small in a relatively large artery to be delineated.

Good local care of distal ulcerations involving the fingers is especially useful in patients with connective tissue disorders. As demonstrated by Porter et al. and Taylor et al., many of these lesions, when treated conservatively with good wound care, will heal spontaneously. In addition to debridement and moist dressings, the addition of medications such as cilostazol may be salutary in some cases. Patients are monitored frequently to determine if there is improvement of symptoms or of their ulceration. Patients who show little improvement or worsening of their skin lesions are generally referred to angiography for further workup.

Brachial artery pseudoaneurysm or occlusion related to cardiac catheterization is one of the most common causes for arterial surgery in the upper extremity. The presence of a pseudoaneurysm may be suggested by a mass at the puncture site, evidence of distal occlusion or embolization, or neurologic complications related to compression within the sheath usually in the nature of paresthesias. Diagnosis can usually be made with duplex ultrasonography, and direct repair with evacuation of the hematoma compressing the median nerve can be performed under local anesthesia. Occlusion of the brachial artery related to catheter insertion often requires more extensive reconstruction, usually involving a segmental bypass with either saphenous vein or cephalic vein from the ipsilateral arm. If recognized relatively promptly, propagated thrombus that may be present either proximal or distal to the occlusion can be easily extracted with a Fogarty balloon catheter. Delayed recognition of this problem will often result in the need for a longer segment bypass with autogenous vein.

The radial artery is the second most common site for upper-extremity iatrogenic arterial injury as a result of catheterization. Fortunately, with the usually good collateral filling across the palm from the ulnar artery, the involved hand may be clinically pale with depressed PVRs, but usually the fingers remain viable. Unless there is some obvious evidence of severe cyanosis or demarcation, we generally would recommend a period of observation following removal of the arterial catheter. Heparinization is desirable but not mandatory. Many of these cases will improve with conservative treatment. In those few cases in which the hand either acutely or subacutely appears to be severely ischemic, repair with a short autogenous bypass of the radial artery above and below the puncture site is usually sufficient to effect improvement.