Upper Extremity Revascularization

Symptomatic arterial disease of the upper extremity is uncommon, accounting for approximately 5% of all cases of extremity ischemia. Ischemia in the upper extremity is caused by a wide variety of diseases, many of which are both nonatherosclerotic and systemic in nature. Occupational, pharmacologic, medical, and athletic factors contribute to many of these diseases. Manifestations of arm ischemia include Raynaud’s phenomenon, pain, and claudication. Embolic symptoms include fingertip gangrene, petechiae, splinter hemorrhages of the nail bed, and livedo reticularis.

The most common symptom of upper extremity ischemia is Raynaud's phenomenon (RP). Patients with RP experience episodic digital ischemia occurring in response to external stimuli including cold and occasionally emotional stress. Patients with RP may be subdivided into two distinct pathophysiologic groups, vasospastic and obstructive, based on the absence or presence of arterial occlusive disease. RP should be distinguished from Raynaud’s disease (RD), a primary vasospastic condition without a clear etiology. Other causes of upper extremity ischemia include additional forms of vasospasm induced by agents such as ergotomine, vasopressors, β-blockers, and cocaine ( Box 1 ). A number of other causes of compromised upper extremity arterial circulation, including thoracic outlet syndrome, trauma, and a variety of arteritides, are discussed in detail In other chapters.

Atherosclerosis remains the most common etiology of clinically significant upper extremity arterial ischemia manifesting as ulcerated plaques with distal embolism, high-grade stenoses, or total occlusion with or without associated evidence of steal phenomena. Sites of prevalent disease include the origin of the subclavian and innominate arteries. Buerger’s disease is often first evident clinically with ischemia of the fingers. An unusual type of vascular disease that occurs in azotemic patients involves calciphylaxis, which can produce calcification of the media of the digital arteries that is demonstrable on plain radiography. These changes are often found in patients with chronic kidney failure or following kidney transplant and can result in gangrene or severe ischemia of the hand. The prognosis associated with this condition is particularly poor.