• Atherosclerosis:
  
  
  
  • Asymptomatic.
    
  • Arm claudication.
    
  • Acute thrombosis.
  
  
• Thromboembolism (acute limb).
  
• Subclavian steal syndrome.
  
• Kommerall’s diverticulum.
  
• Trauma (see Chapter 41).
  
• Thoracic outlet syndrome (see Chapter 45):
  
  
  
  • Arm claudication.
    
  • Post-stenotic aneurysm with embolization.
    
  • Secondary Raynaud’s phenomenon.
  
  
• Raynaud’s (see Chapter 48).
  
  
  
  • Primary.
    
  • Secondary.
  
  
• Vasculitis (see Chapter 46–47).
  
• Complications of renal access (steal syndrome, ischaemia, gangrene, aneurysmal degeneration of fistula, occlusion/thrombosis).

Upper Limb Atherosclerosis

The upper limb is resistant to ischaemia partly because of the generous collateral supply around the shoulder girdle and the collateral-rich profunda brachii branching very proximal from the brachial artery in the upper arm. The most commonly affected vessel is the SCA, but more distal vessels may also be involved (especially in diabetes and chronic renal failure).

Asymptomatic arterial occlusion does not require treatment (e.g. absent radial pulse found on routine examination). Symptomatic disease often presents as arm fatigue or forearm claudication on exercise (e.g. arms working above shoulder level) that is well tolerated, and treatment is only indicated if affecting work or lifestyle. Critical ischaemia is rare. Treatment includes BMT, balloon angioplasty, stenting, open bypass (e.g. carotid-subclavian bypass, SCA-axillary bypass).

Subclavian Steal Syndrome

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