Noninvasive Diagnosis of Upper Extremity Vascular Disease

  • Jocelyn A. Segall
  • Gregory L. Moneta


Symptomatic arterial disease of the upper extremity is uncommon and accounts for approximately 5% of all cases of extremity ischemia. Unlike the lower extremity, where atherosclerosis is by far the most common disorder, ischemia in the upper extremity may be caused by a variety of systemic diseases. The diagnosis of upper extremity arterial disease is often complex and requires a complete history and physical examination, laboratory screening, and noninvasive and possibly invasive examination of the arteries of the upper extremity. In contrast to lower extremity ischemia, surgical intervention is rarely required in patients with upper extremity ischemia and the diagnosis of upper extremity ischemia can often be sufficiently accomplished using only noninvasive diagnostic tests.We have had a long-standing interest in upper extremity ischemia at the Oregon Health & Science University and over the past 30 years have evaluated over 1500 patients. Our noninvasive testing includes segmental arm pressures, digital pressures and arterial waveforms using photoplethysmography (PPG), and testing for cold-induced vasospasm. Duplex evaluation plays a minor role, and arteriography is rarely employed. The noninvasive tests, in combination with the history and physical examination, generally give all the necessary information to secure the diagnosis and guide the treatment for upper extremity ischemia. In this chapter, we will review the disease processes that result in upper extremity ischemia and our diagnostic approach to patients presenting with it.


Connective Tissue Disease Giant Cell Arteritis Duplex Scanning Digital Ulcer Digital Artery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Allen E, Brown G. Raynaud’s disease: A critical review of minimal requisites for diagnosis. Am J Med Sci 1932;83: 187–200.CrossRefGoogle Scholar
  2. 2.
    Edwards JM. Basic data concerning Raynaud’s syndrome. Ann Vasc Surg 1994;8:509–513.CrossRefPubMedGoogle Scholar
  3. 3.
    Hirai M. Cold sensitivity of the hand in arterial occlusive disease. Surgery 1979;85:140–146.PubMedGoogle Scholar
  4. 4.
    Freedman RR, Moten M, Migaly P, Mayes M. Cold-induced potentiation of α2-adrenergic vasoconstriction in primary Raynaud’s disease. Arthritis Rheum 1993;36:685–690.CrossRefPubMedGoogle Scholar
  5. 5.
    Graafsma SJ, Wollersheim H, Droste HT, et al. Adrenoceptors on blood cells from patients with primary Raynaud’s phenomenon. J Vasc Med Biol 1990;2:101–106.Google Scholar
  6. 6.
    Edwards JM, Phinney ES, Taylor LM Jr, et al. Alpha2- adrenergic receptor levels in obstructive and spastic Raynaud’s syndrome. J Vasc Surg 1987;5:38–45.CrossRefPubMedGoogle Scholar
  7. 7.
    Coffman JD, Cohen RA. Alpha2-adrenergic and 5-HT2 receptor hypersensitivity in Raynaud’s phenomenon. J Vasc Med Biol 1990;2:101–106.Google Scholar
  8. 8.
    Freedman RR, Baer RP, Mayes MD. Blockade of vasospastic attacks by alpha2-adrenergic but not alpha1-adrenergic antagonists in idiopathic Raynaud’s disease. Circulation 1995;92:1448–1451.PubMedGoogle Scholar
  9. 9.
    Furspan PB, Chatterjee S, Freedman RR. Increased tyrosine phosphorylation mediates the cooling-induced contraction and increased vascular reactivity of Raynaud’s disease. Arthritis Rheum 2004;50:1578–1585.CrossRefPubMedGoogle Scholar
  10. 10.
    Zamora MR, O’Brien RF, Rutherford RB, et al. Serum endothelin-1 concentrations and cold provocation in primary Raynaud’s phenomenon. Lancet 1990;336;1144– 1147.CrossRefPubMedGoogle Scholar
  11. 11.
    Shawket S, Dickerson C, Hazleman B, et al. Selective suprasensitivity to calcitonin-gene-related peptide in the hands in Raynaud’s phenomenon. Lancet 1989;II:1354– 1357.CrossRefGoogle Scholar
  12. 12.
    Generini S, Seibold JR, Matucci-Cerinic M. Estrogens and neuropeptides in Raynaud’s phenomenon. Rheum Dis Clin North Am 2005;31:177–186.CrossRefPubMedGoogle Scholar
  13. 13.
    Rajagopalan S, Pfenninger D, Kehrer C, et al. Increased asymmetric dimethylarginine and endothelin 1 levels in secondary Raynaud’s phenomenon. Implications for vascular dysfunction and progression of disease. Arthritis Rheum 2003;48:1992–2000.CrossRefPubMedGoogle Scholar
  14. 14.
    Herrick AL. Pathogenesis of Raynaud’s phenomenon. Rheumatology 2005;44:587–596.CrossRefPubMedGoogle Scholar
  15. 15.
    Landry GJ, Edwards JM, McLafferty RB, et al. Long-term outcome of Raynaud’s syndrome in a prospectively analyzed patient cohort. J Vasc Surg 1996;23:76–85.CrossRefPubMedGoogle Scholar
  16. 16.
    Taylor LM Jr, Hauty MG, Edwards JM, Porter JM. Digital ischemia as a manifestation of malignancy. Ann Surg 1987;206:62–71.CrossRefPubMedGoogle Scholar
  17. 17.
    Paw P, Dharan SM, Sackier JM. Digital ischemia and occult malignancy. Int J Colorectal Dis 1996;11:196–197.CrossRefPubMedGoogle Scholar
  18. 18.
    Buerger L. Thromboangiitis obliterans: A study of the vascular lesions leading to presenile spontaneous gangrene. Am J Med Sci 1908;136:567–580.CrossRefGoogle Scholar
  19. 19.
    Mills JL, Porter JM. Buerger’s disease: A review and update. Semin Vasc Surg 1993;6:14–23.PubMedGoogle Scholar
  20. 20.
    Papa M, Bass A, Adar R. Autoimmune mechanisms in thromboangiitis obliterans (Buerger’s disease): The role of the tobacco antigen and the major histocompatibility complex. Surgery 1992;111:527–531.PubMedGoogle Scholar
  21. 21.
    Mackiewicz Z, Piskorz A. Raynaud’s phenomenon following long-term repeated action of great differences of temperature. J Cardiovasc Surg 1977;18:151–154.Google Scholar
  22. 22.
    Kaminski M, Bourgine M, Zins M, et al. Risk factors for Raynaud’s phenomenon among workers in poultry slaughterhouses and canning factories. Int J Epidemiol 1997;26: 371–380.CrossRefPubMedGoogle Scholar
  23. 23.
    Sharma S, Rajani M, Talwar KK. Angiographic morphology in nonspecific aortoarteritis (Takayasu’s arteritis): A study of 126 patients from North India. Cardiovasc Intervent Radiol 1992;15:160–165.CrossRefPubMedGoogle Scholar
  24. 24.
    Pountain G, Hazelman B. Polymyalgia rheumatica and giant cell arteritis. BMJ 1995;310:1057–1059.PubMedGoogle Scholar
  25. 25.
    McCallion WA, Barros S. Management of critical upper extremity ischemia long after irradiation injury of the subclavian and axillary arteries. Br J Surg 1991;78:1136–1138.CrossRefPubMedGoogle Scholar
  26. 26.
    Abbott WM, Maloney RD, McCabe CC, et al. Arterial embolism: A 44 year perspective. Am J Surg 1982;143:460.CrossRefPubMedGoogle Scholar
  27. 27.
    McCready PA, Pairolero PC, Hollier LH, et al. Fibromuscular dysplasia of the right subclavian artery. Arch Surg 1982;117:1243–1245.PubMedGoogle Scholar
  28. 28.
    Nehler MR, Taylor LM Jr, Moneta GM, et al. Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet. Arch Surg 1997;132:527–532.PubMedGoogle Scholar
  29. 29.
    Porter JM, Snider, RL, Bardana EJ, et al. The diagnosis and treatment of Raynaud’s phenomenon. Surgery 1975;77:11– 23.PubMedGoogle Scholar
  30. 30.
    Nielsen SL, Lassen NA. Measurement of digital blood pressure after local cooling. J Appl Phys: Respir Environ Exerc Phys 1977;43:907–910.Google Scholar
  31. 31.
    Lafferty K, de Trafford JC, Roberts VC, Cotton LT. Raynaud’s phenomenon and thermal entrainment: An objective test. BMJ Clin Res 1983;286:90–92.CrossRefGoogle Scholar
  32. 32.
    Singh S, de Trafford JC, Baskerville PA, et al. Digital artery caliber measurement: A new technique of assessing Raynaud’s phenomenon. Eur J Vasc Surg 1991;5:199–205.CrossRefPubMedGoogle Scholar
  33. 33.
    Lutolf O, Chen D, Zehnder T, Mahler F. Influence of local finger cooling on laser Doppler flux and nailfold capillary blood flow velocity in normal subjects and in patients with Raynaud’s phenomenon. Microvasc Res 1993;46:374– 382.CrossRefPubMedGoogle Scholar
  34. 34.
    Strandness DE. Peripheral Arterial System. Duplex Scanning in Vascular Disorders. New York: Raven Press, 1993.Google Scholar
  35. 35.
    McLafferty RB, Edwards JM, Talyor LM Jr, et al. Diagnosis and long-term clinical outcome in patients presenting with hand ischemia. J Vasc Surg 1995;22:361–369.CrossRefPubMedGoogle Scholar
  36. 36.
    Grosveld WJ, Lawson JA, Eikelboom BC, et al. Clinical and hemodynamic significance of innominate artery lesions evaluated by ultrasonography and digital angiography. Stroke 1988;19:958–962.PubMedGoogle Scholar
  37. 37.
    Reed AJ, Fincher RME, Nichols FT. Case report:Takayasu’s arteritis in a middle-aged Caucasian woman: Clinical course correlated with duplex ultrasonography and angiography. Am J Med Sci 1989;298:324–327.Google Scholar
  38. 38.
    Corbin DO, Wood DA, Macintyre CC, Housley E. A randomized double blind cross-over trial of nifedipine in the treatment of primary Raynaud’s phenomenon. Eur Heart J 1986;7:165–170.PubMedGoogle Scholar
  39. 39.
    Teh LS, Manning J, Moore T, et al. Sustained-release transdermal glyceryl trinitrate patches as a treatment for primary and secondary Raynaud’s phenomenon. Br J Rheum 1995;34:636–641.CrossRefGoogle Scholar
  40. 40.
    Pancera P, Sansone S, Secchi S, et al. The effects of thromboxane A2 inhibition (picotamide) and angiotensin II receptor blockade (losartan) in primary Raynaud’s phenomenon. J Intern Med 1997;242:373–376.CrossRefPubMedGoogle Scholar
  41. 41.
    Anderson ME, Moore TL, Hollis S, et al. Digital vascular response to topical glyceryl trinitrate, as measured by laser Doppler imaging, in primary Raynaud’s phenomenon and systemic sclerosis. Rheumatology 2002;41:324–328.CrossRefPubMedGoogle Scholar
  42. 42.
    Coleiro B, Marshall SE, Denton CP, et al. Treatment of Raynaud’s phenomenon with the selective serotonin reuptake inhibitor fluoxetine. Rheumatology 2001;40:1038– 1043.CrossRefPubMedGoogle Scholar
  43. 43.
    Rose GD, Carlson JG. The behavioral treatment of Raynaud’s disease: A review. Biofeedback Self Regul 1987;12:257–272.CrossRefPubMedGoogle Scholar
  44. 44.
    Appiah R, Hiller S, Caspary L, et al. Treatment of primary Raynaud’s syndrome with traditional Chinese acupuncture. J Intern Med 1997;241:119–124.CrossRefPubMedGoogle Scholar
  45. 45.
    el-Gammal TA, Blair WF. Digital periarterial sympathectomy for ischaemic digital pain and ulcers. J Hand Surg 1991;16:382–385.Google Scholar
  46. 46.
    King TA, Marks J, Berrettoni BA, Seitz WH. Arteriovenous reversal for limb salvage in unreconstructible upper extremity arterial occlusive disease. J Vasc Surg 1993;17: 924–932.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2010

Authors and Affiliations

  • Jocelyn A. Segall
    • 1
  • Gregory L. Moneta
    • 2
  1. 1.Vascular Fellow, Division of Vascular SurgeryOregon Health and Science UniversityPortlandUSA
  2. 2.Division of Vascular SurgeryOregon Health Science UniversityPortlandUSA

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