Vascular Evaluation of the Hand

Christopher M. Jones

Beatrice L. Grasu

INTRODUCTION

A diagnosis of vascular insufficiency of the upper extremity begins with taking a thorough history and performing a physical exam.
Hand held doppler ultrasounds are useful to audibly and visually evaluate normal or obstructed vessels throughout the upper extremity (UE).
The vascular laboratory includes several crucial tests to evaluate vascular insufficiency including Doppler fluxometry, plethysmography, cold stress testing, and nail fold capillaroscopy.
Angiography is the gold standard for evaluation of vasculature, but the evolution of CT and magnetic resonance imaging (MRI) has improved visualization of upper limb vessels in a noninvasive manner.

VASCULAR PATHOLOGY IN THE UPPER EXTREMITY

Vascular disorders are much more common in the lower limb than in the upper limb; however, UE vascular disorders may be just as debilitating.
May present as part of a systemic disorder affecting both extremities or as a specific injury to one UE
- Upper extremity bloodflow is both thermoregulatory and nutritional with symptoms of
  - cold sensitivity
  - signs of ulceration
  - skin changes such as hair loss
  - numbness, pain, and/or gangrene¹
Vaso-occlusive disease
- Physical obstruction
- Structural abnormalities
- Vasospastic disease
- Combination
Primary goal of treatment—restore pulsatile blood flow to nutritional capillary beds

VASCULAR ANATOMY OF THE UPPER EXTREMITY

Arterial supply is derived from the subclavian artery
- Originates from the brachiocephalic (innominate) artery on the right
- Directly from the aortic arch on the left
- The subclavian artery branches to the head and neck before it becomes the axillary artery at the level of the first rib
  - First supplies branches to both the shoulder and scapula
- The axillary artery then becomes the brachial artery just below the axilla.
- The brachial artery travels medially down the arm and elbow to give off a deep branch and collateral vessels that provide an arterial anastomosis to the elbow.
  - Terminates just distal to the elbow in its bifurcation to the radial and ulnar arteries, which course along their respective sides of the forearm
- The ulnar and radial arteries give off recurrent arteries to also provide collateral circulation around the elbow.
  - The ulnar artery also gives off an interosseous branch that trifurcates into posterior, recurrent, and anterior branches
  - Further distally, the ulnar artery becomes the superficial palmar arch.
  - The radial artery becomes the deep palmer arch.
  - Both arches of the hand give off arterial branches to supply the thumb and fingers.²
Venous system of the UE includes a superficial and deep network.
- Superficially, the cephalic vein is located more lateral in the upper arm; the basilic vein is located more medially.
  - These two veins typically join just distal to the elbow at the median antecubital vein.
- The deep system includes the radial and ulnar veins in the forearm, which unite caudal to the elbow to form the brachial veins.
- The brachial veins join the basilic vein typically at the level of the teres major muscle and continue as the axillary vein.
- The axillary vein passes through the axilla and crosses the first rib before becoming the lateral portion of the subclavian vein.
  - The medial portion of the subclavian vein includes the external and internal jugular vein, which all flow into the brachiocephalic vein.

HISTORY AND PHYSICAL EXAMINATION

Crucial portion of the evaluation and must include:
- Past medical history, cardiac history, smoking use
- Any similar symptoms in the contralateral extremity or lower extremities
- Patients may not report any symptoms from mild vascular disease; however, they may describe pain from repetitive use of their UEs causing intermittent claudication.
As the disease progresses, skin, nail, and hair changes and pain may occur.
Evaluate patient’s general appearance and perform a cardiovascular examination followed by examination of the affected extremity.
- Compare the affected upper limb to the contralateral limb.
- Palpate the radial, ulnar, and brachial pulses for intact arterial flow.
- Inspect skin for color or pallor, ulcerations, hair loss, or fingernail changes that may display hallmark signs of embolic or other signs of chronic ischemia (Figure 64.1).
Specific physical examination tests for vascular pathology
- Allen test (Figure 64.2)
  - Physical exam maneuver that can identify specific arterial patency.¹
  - Unlike ulnar artery aneurysms, radial artery aneurysms do not generally cause arterial occlusion.
    - Test might demonstrate normal flow through the radial artery despite pathology.
  - Performing the test
    - Elevate the hand and ask the patient to make a fist for 30 seconds to 1 minute.
    - Apply pressure to both the radial and ulnar arteries to occlude them.
    - With hand still elevated, ask the patient to open the fist. Observe hand pallor.
    - Release pressure off one of the arteries, but maintain pressure on the other.
    - Determine how long it takes for the color to return to the hand.
    - Repeat the examination but reverse which artery remains occluded.
    - A normal exam is observed when color returns within six seconds
- Digital Allen test (Figure 64.3)
  - Elevate hand/perform digital artery occlusion at base of digit.
  - Flex the finger several times to cause blanching and then the hand is lowered.
  - If the finger remains blanched after lowering the hand and releasing compression of one digital artery, then the released digital artery is considered compromised.¹
- Handheld Doppler evaluates blood flow or velocity through the radial and ulnar arteries at the wrist and the digital arteries.
  - Allows “mapping” of the arterial network
  - Several types of Doppler transducers to match specific requirements for physiologic application
    - Suction-on Doppler flow probes or suture-down transducers
    - Extravascular Doppler flow transducer is most commonly seen for evaluation of the UE in particular
      - ▲ Stainless steel tube with a 1 mm diameter piezoelectric crystal mounted at a 45° angle inside
      - ▲ Angle the probe at 45° to the vascular bed while using conductive gel and avoiding excessive compression (Figure 64.4)
      - ▲ The reflected sound waves result from the movement of blood cells and vary with blood flow velocity. This velocity is visualized in a triphasic flow pattern if it is normal, whereas
        areas of occlusion or compression also have characteristic flow patterns (Figure 64.5).
      - ▲ There is no correlation between the arterial Doppler signal and systolic blood pressure or actual blood volume.¹
      - ▲ The Allen test may be performed while using the handheld Doppler to assess the arterial flow in the digits (Figure 64.6).
- Adson maneuver
  - Arm abduction and extension while rotating the patient’s head to the ipsilateral elevated arm and extending the neck after deep inspiration
  - Palpate the radial pulse before and during the maneuver. If pulse decreases or is completely absent, the maneuver is positive for diagnosis of thoracic outlet obstruction
  - Patients frequently complain of vague, diffuse arm pain or fatigue with activity, especially overhead exercises

FIGURE 64.1 Ischemic ulcerations at the tips of second through fifth digits prior to revascularization (A). Nail changes also known as splinter hemorrhages indicating digital vessel emboli and capillary ischemia (B). Originally printed in Grasu BL, Jones CM, Murphy MS. Use of diagnostic modalities for assessing upper extremity vascular pathology. Hand Clin. 2015;31(1):1-12. Courtesy of R.D. Katz, MD, Baltimore, Maryland.

FIGURE 64.2 Perform the Allen test to assess for ulnar versus radial dominance by compressing both the ulnar and radial arteries until the hand becomes pale (A). Then release pressure on the ulnar artery while maintaining compression on the radial artery (B). Evaluate for capillary perfusion and then repeat the test by reversing the compressed vessel (C). Originally printed in Grasu BL, Jones CM, Murphy MS. Use of diagnostic modalities for assessing upper extremity vascular pathology. Hand Clin. 2015;31(1):1-12.

FIGURE 64.3 A,B, The Allen test can also be performed in the hand to assess radial and ulnar digital artery circulation. Originally printed in Grasu BL, Jones CM, Murphy MS. Use of diagnostic modalities for assessing upper extremity vascular pathology. Hand Clin. 2015;31(1):1-12.

FIGURE 64.4 Using a conductive gel, angle the Doppler probe about 45° to the vessel being studied. Originally printed in Grasu BL, Jones CM, Murphy MS. Use of diagnostic modalities for assessing upper extremity vascular pathology. Hand Clin. 2015;31(1):1-12.

FIGURE 64.5 Normal arterial waveform patterns of the Doppler signal have a triphasic pattern (A) while obstructed (B) and stenotic (C) vessels have these characteristic patterns. Reprinted with permission from Koman LA. Diagnostic study of vascular lesions. Hand Clin. 1985;1(2):221. Copyright © Elsevier.

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