Upper extremity arterial abnormalities

TOS

Muscular band, cervical rib or fibrous band crosses the brachial plexus in an abnormal location that causes compression with certain arm maneuvers

Most pts asymptomatic

May see dull aching pain, radiating from the point of compression

May see numbness, pain, increased symptoms with certain arm/neck positions or exercise, may see extremity swelling with venous TOS

Intermittent swelling with pt position

Neurogenic TOS

MOST COMMON TYPE

Compression of the brachial plexus from cervical ribs, anterior scalene muscles and ligaments

Causes paresthesia, numbness, pain

US will not identify cause of symptoms

Arterial TOS

Least common

Subclavian artery compression from the head of the humerus

Venous TOS

Subclavian vein compressed against the first rib and anterior scalene muscle with abduction of the arm

Also called Paget-schroetter syndrome or effort thrombosis

Adson’s maneuver

Palpate the radial pulse on the affected side with the elbow fully extended

Have the pt rotate their head to the side being tested and extend the neck

Then abduct, extend and laterally rotate the shoulder

From this position, have the pt take a deep breath and hold

Assess the pulse response

A positive test is a decrease in pulse vigor from the starting position to the final position

Hypothenar Hammer syndrome

Ulnar artery is commonly affected because it crosses over the hook of hamate bone

Can be caused by repetitive compression or blunt trauma

Associated with Raynauds

Pain in the palm of the hand and with cold sensation

Most commonly causes ischemia of the fourth and 5th fingers

Positive Tinel sign = distal paresthesia induced by compression of the affected portion entrapped ulnar nerve

Positive Allen test

Occlusion of the distal ulnar artery

May also see irregular contour or aneurysm of the ulnar artery

Takayasu arteritis

Hypertrophic areas of inflamed tissue usually found in the aorta and its branched

Associated with supravalvular stenosis and aortic coarctation

Commonly affects the subclavian and carotid arteries

Can also affect the renal arteries

Most commonly seen in young females

Raynaud’s syndrome

Vasospastic disorder that presents as a response to cold or emotional stimuli

>70% occurs in females

Can be associated with lupus, scleroderma, rheumatoid arthritis

Primary Raynaud’s syndrome

Called raynaud syndrome/disease

Occurs in a NORMAL vascular system

Bilateral digital arterial spasm - INTERMITTENT

More common in women

Symptoms only occur when arterial spasm is present and occur intermittently for more than 2 years

Secondary Raynaud’s syndrome

Called raynaud phenomenon

Occurs in ABNORMAL or obstructed vascular system with vasoconstriction causing constant ischemia

May be unilateral

Pain is usually CONSTANT with significant arterial obstruction

Presents with Crest syndrome, in which tissue necrosis results from spastic and occlusive disease

Crest syndrome

Involves symptoms of generalized calcinosis, Raynaud phenomenon, esophageal dysfunction, scleroderma and telangiectasia

Raynaud’s syndrome is more common in the hands than the _____

Feet

If the baseline PPG tracings are abnormal, cold sensitivity testing should…

Not be performed

Atherosclerotic disease in the upper extremities

Uncommon finding

Upper extremities seem to be somewhat resistant to atheroma formation

Signs and symptoms are the same as PAD in the lower extremities

Subclavian steal can be related to atheroma formation in the subclavian stery

Normal Doppler waveforms demonstrate a high resistance, triphasic waveform with a spectral window

Upper arterial collateral formation

Subclavian obstruction - Subclavian steal, abdominal and thoracic wall arteries

Axillary obstruction - Thoracic wall or shoulder

Brachial obstruction - forearm, palmar arches with retrograde filling

Steal syndrome most commonly occurs with what type of AV fistula

Radioscephalic

What exam techniques are preferred for evaluation of TOS

PPG or PVR exams

What is the first position used for TOS testing

Seated upright with both hands resting palm up on the thighs

Which system setting should be significantly decreased to best display flow changes with maneuvers performed for TOS evaluation

Sweep speed

When evaluating a pt using PVR techniques, the cuff should be placed on the ___________ and when evaluating the pt using PPG techniques, the sensor should be placed on the __________

Upper arm; 2nd digit

When you note abnormal changes to the PPG tracing on TOS evaluation, what should you do next?

Ask the pt if they are experiencing symptoms

A positive Tinel test indicates what abnormality is present?

Hypothenar Hammer syndrome

What branch arteries are most commonly affected by Takayasu arteritis

Subclavian and carotid

If a pt experiences hand/finger pain when exposed to cold temperatures, how will you differentiate primary from secondary Raynaud syndrome

Perform an upper extremity Duplex exam

After confirming there is no atherosclerotic disease in the upper extremity, what is the next step in evaluating suspected Raynaud disease?

Obtain a digital pressure and calculate the digital brachial index

Double peaked waveform is a characteristic of Raynaud disease seen on:

PVR tracings