Part 3/Chapter 9/19-min read

Upper Extremity Arterial Disease

Comprehensive coverage of upper extremity arterial pathology including TOS, hypothenar hammer syndrome, and Raynaud phenomenon

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·20 sections · 38 references

Atherosclerosis

Atherosclerotic disease is the most common etiology of chronic upper extremity arterial occlusive disease in older adults and typically involves the proximal great vessels, particularly the ostial/proximal subclavian artery (and less commonly the innominate), followed by axillary/brachial disease.

  • Inter-arm systolic blood pressure (BP) difference >=15-20 mmHg, diminished pulses, supraclavicular bruit.
  • Vertebrobasilar symptoms with arm exertion suggests subclavian steal (see 7Ch. 7).
  • Angina/ischemia in patients with a left internal mammary artery (LIMA) coronary graft suggests coronary-subclavian steal and warrants prompt evaluation.

Indications for revascularization (typical)

Revascularization is generally recommended for symptomatic lesions (rather than asymptomatic stenosis) and should be individualized based on anatomic severity, symptom mechanism, and procedural risk.

Common indications include:

  1. Lifestyle-limiting arm claudication attributable to subclavian/innominate stenosis/occlusion.
  2. Critical hand ischemia (rest pain, ulcers, tissue loss) when due to correctable proximal inflow disease.
  3. Embolization from a proximal lesion (ulcerated plaque or aneurysmal disease) with recurrent distal ischemic events.
  4. Subclavian steal syndrome with reproducible vertebrobasilar symptoms and confirmed hemodynamic steal physiology.
  5. Coronary-subclavian steal in patients with LIMA grafts (symptomatic or high-risk anatomy).
  6. Pre-emptive left subclavian artery (LSA) revascularization may be indicated in selected patients undergoing 6thoracic endovascular aortic repair (TEVAR) when coverage risks posterior circulation or spinal cord ischemia.

Treatment strategy (overview)

  • Best medical therapy (antiplatelet therapy, statin therapy, smoking cessation, BP/diabetes control) is mandatory in all patients because upper extremity atherosclerosis is a marker of systemic cardiovascular risk.
  • Endovascular-first (angioplasty +/- stenting) is commonly favored for focal proximal stenoses due to high technical success and low morbidity; open reconstruction is reserved for long occlusions, failed endovascular therapy, complex anatomy, or specific operative contexts.

Trauma

Hypothenar hammer syndrome (HHS) results from repetitive blunt trauma to the hypothenar eminence, injuring the ulnar artery at the hamate with intimal disruption, thrombosis, aneurysm formation, and distal embolization. It is classically seen in manual laborers using impact tools and in athletes with repetitive hand impact.

Workup

  • Focused history (occupation, repetitive trauma, tobacco, vasospastic symptoms) and exam (ulnar-sided ischemia, hypothenar tenderness/mass).
  • Allen test (screening) plus digital pressures/photoplethysmography to quantify ischemia; consider cold challenge if vasospasm suspected.
  • Duplex ultrasound to assess ulnar artery patency/aneurysm and palmar arch flow; computed tomography angiography (CTA)/magnetic resonance angiography (MRA)/digital subtraction angiography (DSA) for operative planning and to define distal embolic burden.

Management

  • Initial: eliminate inciting trauma, smoking cessation, protective padding, and antiplatelet therapy (particularly in embolic presentations).
  • Acute embolic ischemia: consider catheter-directed thrombolysis or thrombectomy in appropriately selected patients, with attention to ischemia duration and distal target vessel size. Principles parallel 10PAD acute limb ischemia management.
  • Operative: resection of diseased ulnar segment with vein interposition graft is preferred when the palmar arch is incomplete or when durable inflow is required. If the palmar arch is complete and distal perfusion is adequate, ligation may be reasonable.
  • Avoid stenting across the wrist because of motion-related failure and fracture risk.

When to broaden the differential

If symptoms are bilateral, episodic, or triggered by cold/stress, consider vasospastic disease (see "Raynaud phenomenon") or inflammatory vasculitis (see "Other").

Thoracic Outlet Syndrome

Arterial thoracic outlet syndrome (arterial TOS) is caused by chronic extrinsic compression of the subclavian artery in the scalene-costoclavicular space, most often due to a cervical rib, anomalous first rib, or fibrous bands. Repetitive trauma can lead to intimal injury, post-stenotic dilatation/aneurysm, mural thrombus, and distal embolization.

Diagnostic standards

  • Diagnosis requires correlation of symptoms (hand ischemia, digital emboli, exertional arm fatigue) with objective imaging.
  • Recommended imaging includes dynamic duplex ultrasonography and computed tomography angiography (CTA)/magnetic resonance angiography (MRA) performed in neutral position and with provocative positioning (abduction/external rotation) to document compression and associated arterial pathology (aneurysm, thrombus).

Treatment principles

  • Definitive management is thoracic outlet decompression (first rib and/or cervical rib resection with scalenectomy), combined with arterial reconstruction when aneurysm, thrombus, or fixed arterial damage is present (patch angioplasty, endarterectomy, or interposition graft).
  • Isolated endovascular stenting across the thoracic outlet without decompression is not recommended due to persistent external compression and risk of stent deformation/fracture and recurrent embolization.
  • Distal embolization should be treated with thrombectomy or thrombolysis when clinically indicated; the embolic source must be addressed to prevent recurrence.

Other

This section highlights non-atherosclerotic causes of upper extremity ischemia. A structured approach is to determine whether ischemia is primarily due to: 1) inflammatory arterial wall disease, 2) embolism/thrombosis, 3) extrinsic compression, or 4) iatrogenic/radiation injury.

Vasculitis

Examples include Takayasu arteritis, giant cell arteritis, and Buerger disease.

  • Workup typically includes inflammatory markers and targeted rheumatologic evaluation plus vascular imaging.
  • In large-vessel vasculitis, FDG-PET/CT can support diagnosis and map inflammatory activity when available and clinically appropriate.
  • Revascularization is generally preferred during disease quiescence, with concomitant immunosuppression coordinated with rheumatology; restenosis risk is higher in active inflammatory disease.

Embolic disease

Common sources include atrial fibrillation, valvular disease, mural thrombus, aortic arch atheroma, and proximal arterial lesions such as subclavian aneurysm (including aneurysms associated with arterial TOS).

  • Initial management of suspected acute arterial embolism includes immediate systemic anticoagulation unless contraindicated, while defining the source and limb threat.
  • Definitive therapy aligns with acute limb ischemia principles (open embolectomy, catheter-directed thrombolysis, or endovascular therapy based on timing and thrombus burden). See 10PAD.

Radiation-induced injury

Consider in patients with prior thoracic/neck radiation. Dense fibrosis and long-segment disease may reduce endovascular durability; open reconstruction may be required in selected cases.

Buerger disease (thromboangiitis obliterans)

Buerger disease is a distal, segmental inflammatory vaso-occlusive disease strongly linked to tobacco exposure, often presenting with digital ischemia and superficial thrombophlebitis.

  • Absolute tobacco cessation is the only proven disease-modifying therapy.
  • Revascularization is rarely feasible due to distal target limitations; consider sympathectomy or vasodilator strategies only in carefully selected refractory cases.

Upper Extremity Pathophysiology

  • Atherosclerotic lesions: cause flow-limiting stenosis/occlusion.
  • Trauma: disruption of intima → thrombosis, pseudoaneurysm, arteriovenous fistula.
  • TOS: repeated compression → intimal hyperplasia, mural thrombus, distal embolization.
  • Vasculitis: chronic inflammation, wall thickening, stenosis, or aneurysm.
  • Embolism: distal ischemia, often digital gangrene.

Upper Extremity Clinical Presentation

Upper extremity arterial disease presents along a spectrum from asymptomatic disease to acute and chronic ischemic syndromes. Because upper extremity atherosclerosis often reflects systemic vascular disease, symptoms should trigger a cardiovascular risk assessment and optimization.

Common clinical patterns

  1. Proximal inflow disease (subclavian/innominate)
  2. - Arm claudication, fatigue, exertional pain.
  3. - Subclavian steal: vertebrobasilar symptoms provoked by arm exertion due to retrograde vertebral flow.
  4. - Coronary-subclavian steal: angina/ischemia in patients with LIMA grafts.
  1. Distal occlusive/embolic disease (brachial/forearm/digital)
  2. - Blue finger syndrome, digital ulcers/gangrene, acute pain with pallor/coolness and neurologic deficits (advanced ischemia).
  1. Extrinsic compression syndromes
  2. - Arterial TOS: exertional symptoms and recurrent distal embolization.
  1. Dialysis access-related ischemia ("steal syndrome")
  2. - Hand pain, numbness, coolness, tissue loss, often improved with access compression during bedside testing.

Terminology

The term chronic limb-threatening ischemia (CLTI) is reserved for lower extremity disease; upper extremity ischemia is described by etiology and severity (e.g., chronic ischemia, acute embolic ischemia, TOS-related embolization). See 10PAD.

Clinical examination

A focused vascular exam should define inflow (subclavian/axillary), outflow (brachial/forearm), and hand perfusion.

Key elements

  • Palpate brachial, radial, and ulnar pulses; assess capillary refill, temperature gradient, and digital perfusion.
  • Auscultate for supraclavicular/subclavian bruits and evaluate for cervical rib/space-occupying findings when TOS is suspected.

Blood pressure

Measure bilateral brachial pressures. An inter-arm systolic BP difference >=15-20 mmHg suggests hemodynamically significant subclavian stenosis in an appropriate clinical context.

Hand collateral assessment

Perform Allen test as a bedside screen of palmar arch adequacy when planning radial artery harvest, catheterization, or interventions impacting the forearm circulation; abnormal results should be confirmed with duplex/PPG-based testing.

Non-invasive

Duplex ultrasound (first-line)

Duplex ultrasound is the usual first-line test for suspected upper extremity occlusive disease because it can:

  • Localize stenosis/occlusion and characterize plaque.
  • Identify vertebral artery flow direction in suspected subclavian steal.
  • Provide validated velocity criteria for grading subclavian stenosis severity.

Physiologic testing

Physiologic studies help quantify ischemia and are especially useful for distal/digital disease:

  • Wrist-brachial index and segmental pressures (interpretation principles parallel ankle-brachial index (ABI) methodology).
  • Digital pressures/photoplethysmography (PPG), including cold challenge when vasospasm is suspected (see "Raynaud phenomenon").
  • Dialysis access ischemia: compare digital pressures and waveforms with and without access compression to support steal physiology.

Imaging

computed tomography angiography (CTA)/magnetic resonance angiography (MRA) are preferred noninvasive modalities for anatomic mapping and procedural planning when intervention is being considered.

  • CTA: high spatial resolution, rapid acquisition; useful for calcified ostial lesions and for mapping arch/subclavian origins.
  • MRA: alternative in iodinated contrast allergy or when minimizing radiation; interpret with awareness of flow-related artifacts.

Dynamic protocols

In suspected arterial TOS, perform CTA/MRA with arm positioning (neutral and provocative) to demonstrate compression and post-stenotic changes.

digital subtraction angiography (DSA)

Digital subtraction angiography (DSA) remains the reference standard for luminal assessment and is typically performed when endovascular treatment is planned or when noninvasive studies are discordant.

Special investigations

When to consider specialized testing

  • Arterial TOS: use standardized dynamic duplex and cross-sectional imaging (neutral vs abduction/external rotation) to document compression and arterial sequelae (aneurysm, thrombus).
  • Complex ostial subclavian lesions: consider adjunctive intraprocedural imaging (e.g., IVUS) to optimize stent sizing/landing in ostial disease where angiography may underestimate vessel diameter due to overlap and eccentric plaque. (Evidence base is extrapolated from broader endovascular practice.)

Medical therapy

Medical therapy serves two goals in upper extremity arterial disease:

  1. Reduce systemic cardiovascular risk (myocardial infarction (MI), stroke, cardiovascular death)
  2. Reduce limb events and maintain patency after revascularization

Baseline therapy for atherosclerotic upper extremity disease

  • Antiplatelet therapy: single antiplatelet therapy is standard for symptomatic atherosclerotic disease. Clopidogrel demonstrated benefit over aspirin in atherosclerotic vascular disease populations (including peripheral arterial disease (PAD) subgroups).
  • High-intensity statin therapy: reduces major cardiovascular events in high-risk atherosclerotic populations.
  • Smoking cessation: associated with improved outcomes and reduced mortality in symptomatic PAD populations (extrapolated to systemic atherosclerosis management).
  • Intensively manage blood pressure (BP), diabetes, and lifestyle according to general vascular prevention standards.

Antithrombotic therapy after subclavian/innominate stenting (pragmatic approach)

Evidence for dual antiplatelet therapy (DAPT) duration in subclavian stenting is limited; practice is typically extrapolated from peripheral and carotid stenting experience.

  • DAPT (aspirin + clopidogrel) for 1-3 months, then single antiplatelet therapy long term, individualized by bleeding risk and competing indications (e.g., atrial fibrillation).
  • Consider dual-pathway inhibition (low-dose rivaroxaban plus aspirin) in selected patients with polyvascular atherosclerosis and acceptable bleeding risk; this strategy reduced cardiovascular and limb events in PAD populations and may be considered after non-coronary peripheral interventions on an individualized basis.

Lipid intensification for very high-risk disease

In very high-risk atherosclerotic disease with persistent low-density lipoprotein (LDL) elevation despite statin therapy, consider additional lipid-lowering therapy based on cardiovascular outcome trials. Additionally, lipoprotein(a) (Lp(a)) should be measured at least once in a lifetime to identify patients at high risk for atherosclerotic cardiovascular disease (ASCVD).

Embolic disease

For suspected acute arterial embolism, initiate systemic anticoagulation unless contraindicated while definitive source evaluation proceeds.

Endovascular therapy

Endovascular therapy (angioplasty +/- stenting) is commonly used for symptomatic subclavian/innominate stenosis because of high technical success and low peri-procedural morbidity in appropriately selected patients.

Typical indications

  • Lifestyle-limiting arm claudication attributable to inflow stenosis.
  • Subclavian steal with reproducible vertebrobasilar symptoms and documented hemodynamic steal.
  • Coronary-subclavian steal in LIMA graft patients.
  • Embolic manifestations from proximal lesions when anatomy is suitable (often alongside treatment of the embolic source).

Technical considerations (proximal subclavian)

  • Ostial lesions require precise stent positioning to cover the plaque while avoiding protrusion into the aortic arch when possible.
  • Assess vertebral origin and dominance; manage embolic risk and neurologic symptoms in coordination with cerebrovascular evaluation (see 7Ch. 7).
  • Report outcomes using standardized definitions (technical success, primary/assisted/secondary patency, target lesion revascularization).

Outcomes (typical)

  • Technical success for subclavian stenosis interventions is commonly reported as >90% in contemporary practice.
  • Mid-term patency varies by lesion type and location; restenosis and reintervention remain expected failure modes requiring surveillance.

When TEVAR requires LSA coverage, selective LSA revascularization is recommended to reduce risks of posterior circulation ischemia and spinal cord ischemia in appropriately selected patients.

Upper Extremity Open Surgery

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Open reconstruction remains an essential option for upper extremity inflow disease, particularly when lesions are long, occlusive, recurrent after endovascular therapy, or when clinical context favors durable reconstruction (e.g., younger patients, complex anatomy, or concomitant open procedures).

Common proximal reconstructions

  1. Carotid-subclavian bypass (CSB)
  2. Subclavian-carotid transposition (SCT)

These procedures are also used to preserve LSA flow when required for 6thoracic endovascular aortic repair (TEVAR) or to treat coronary-subclavian steal in LIMA graft patients.

Additional options (selected settings)

  • Axillo-axillary bypass (selected inflow patterns or reoperative fields).
  • Endarterectomy for focal lesions in selected anatomic segments.
  • Embolectomy/thrombectomy (Fogarty catheter) for acute embolic occlusion when appropriate, with evaluation and treatment of the embolic source.

Outcomes (general expectations)

Open reconstructions are generally durable with good long-term patency when appropriately selected, but carry higher perioperative morbidity than endovascular therapy and require careful stroke risk mitigation for carotid-based inflow procedures.

Upper Extremity Hybrid Procedures

Hybrid approaches combine open exposure/reconstruction with endovascular therapy and are useful when:

  • There is multilevel disease requiring both inflow correction and distal optimization.
  • Open access improves endovascular safety (e.g., difficult arch anatomy, need for controlled access).
  • Concomitant procedures are planned (e.g., left subclavian artery (LSA) revascularization plus endovascular arch/descending thoracic work).
  • Complex aneurysmal disease involves the subclavian-axillary-brachial axis, where hybrid exclusion and bypass maintain distal perfusion.

Planning principles

  • Define the dominant failure risk (inflow vs outflow vs embolic source) and sequence steps accordingly.
  • Use standardized reporting (primary/assisted/secondary patency and reintervention).

Hybrid revascularization is established in peripheral arterial practice; outcomes depend on lesion complexity and patient selection.

Upper Extremity Follow-up

Follow-up should combine clinical assessment, risk-factor optimization, and hemodynamic surveillance tailored to the treated segment.

Suggested surveillance after subclavian/innominate revascularization

(Adapted from general vascular surveillance principles.)

  • Baseline exam and duplex ultrasound within 4-6 weeks post-procedure.
  • Repeat duplex at 6 months, 12 months, then annually if stable.
  • Earlier assessment for recurrent claudication, neurologic symptoms suggestive of recurrent steal, loss of pulses, or recurrent BP differential.

Registry benchmarking

National and international registries (e.g., Swedvasc, Vascunet) support benchmarking of reintervention and patency outcomes across vascular procedures and can inform quality improvement.

Long-term medical therapy reinforcement

Ensure long-term antiplatelet therapy and lipid-lowering therapy consistent with systemic atherosclerosis management, and smoking cessation counseling at every visit.

Upper Extremity Tables

Table 9.1Treatment options for proximal upper extremity inflow disease (subclavian/innominate)
Comparison A

Best medical therapy

Trade-offs
  • Does not correct hemodynamic steal/ischemia
Comparison B

Endovascular angioplasty +/- stenting

Trade-offs
  • Restenosis
  • stent deformation in dynamic compression syndromes
Comparison C

Carotid-subclavian bypass / subclavian-carotid transposition

Trade-offs
  • Operative morbidity
  • stroke risk mitigation required
Table 9.2TreatmentEvidence-based medical therapy (systemic atherosclerosis focus)
Antiplatelet therapy
**Evidence base**
CAPRIE
**Clinical use in upper extremity arterial disease**
Baseline therapy for symptomatic atherosclerotic disease
Statin therapy
**Evidence base**
HPS
**Clinical use in upper extremity arterial disease**
High-intensity statin for secondary prevention
Dual-pathway inhibition
**Evidence base**
COMPASS; VOYAGER peripheral arterial disease (PAD)
**Clinical use in upper extremity arterial disease**
Consider in select high-risk patients post-intervention if bleeding risk acceptable
Smoking cessation
**Evidence base**
PAD outcomes data
**Clinical use in upper extremity arterial disease**
Strongly recommended; improves long-term outcomes
Table 9.3TreatmentDialysis access-induced hand ischemia (steal): evaluation clue
Symptoms improve with access compression; digital waveforms improve
**Interpretation**
Supports access-related steal physiology
Persistent ischemia despite compression
**Interpretation**
Consider inflow disease, distal arterial disease, or neuropathic etiologies
Table 9.4TreatmentArterial TOS
Arterial TOS
**Key diagnostics**
Dynamic duplex + computed tomography angiography (CTA)/magnetic resonance angiography (MRA)
**Treatment**
Decompression + arterial reconstruction when indicated; avoid isolated stenting
HHS
**Key diagnostics**
Allen test + duplex + angiography if needed
**Treatment**
Risk modification; vein interposition or ligation (selected)
Buerger disease
**Key diagnostics**
Clinical + angiography
**Treatment**
Absolute smoking cessation; limited role for revascularization
Raynaud phenomenon
**Key diagnostics**
Capillaroscopy/autoantibodies (secondary)
**Treatment**
CCB first-line; PDE5 inhibitors for refractory disease

Arterial thoracic outlet syndrome (TOS): diagnostic standards and surgical decompression

Arterial thoracic outlet syndrome (aTOS) requires differentiation from neurogenic and venous forms. Standardized diagnostic imaging includes dynamic duplex ultrasonography and computed tomography angiography (CTA) or magnetic resonance angiography (MRA) performed in both neutral position and with abduction/external rotation to document arterial compression, morphologic lesions such as post-stenotic dilatation or aneurysm, and thrombus. It is critical to distinguish pathological compression from physiological variants, as positional arterial compression can be observed in up to 20% of asymptomatic individuals; thus, a diagnosis of aTOS typically requires evidence of structural arterial damage or distal complications . Indications for surgical intervention include documented arterial compression with aneurysm or thrombus formation, or recurrent ischemia with distal embolization. The surgical approach consists of first rib or cervical rib resection combined with scalenectomy, which forms the cornerstone of treatment for aTOS. When aneurysm or focal intimal disease is present, concomitant arterial reconstruction is performed using endarterectomy, patch angioplasty, or interposition vein grafting. Isolated stenting across the thoracic outlet without decompression is not recommended due to persistent external compression and the risk of stent fracture. Evaluation and management of distal embolization with thrombectomy or catheter-directed thrombolysis should be performed as clinically indicated.

Hypothenar hammer syndrome (HHS): workup and management

Hypothenar hammer syndrome results from repetitive blunt trauma to the hypothenar eminence, causing injury to the ulnar artery at the level of the hamate bone and the superficial palmar arch. This condition predominantly affects manual laborers, mechanics, jackhammer operators, and athletes such as baseball players, tennis players, and cyclists. Patients typically present with ulnar-sided digital ischemia, cold sensitivity, and characteristic corkscrew appearance of the ulnar artery on imaging. The diagnostic workup begins with a focused physical examination including the Allen test to assess palmar arch competency. Duplex ultrasonography evaluates for ulnar artery irregularity, aneurysm formation, or thrombosis. Digital pressures and photoplethysmography, optionally with cold challenge testing, assess the severity of digital ischemia. Computed tomography angiography (CTA), magnetic resonance angiography (MRA), or digital subtraction angiography provides detailed anatomic information for operative planning. Management strategies include risk-factor modification, occupational counseling, smoking cessation, and antiplatelet therapy. Surgical treatment is indicated for aneurysm formation or ongoing distal embolization and consists of resection of the diseased ulnar artery segment with interposition vein grafting or, when the palmar arch is complete, simple ligation. Catheter-directed thrombolysis or open thrombectomy may be considered for acute embolic events. Stenting across the wrist joint is contraindicated due to high rates of motion-related failure .

Buerger disease (Thromboangiitis obliterans) in upper extremity disease

Buerger disease, also known as thromboangiitis obliterans (TAO), is an inflammatory vaso-occlusive disorder that predominantly affects young tobacco users. The disease is characterized by distal, segmental arterial occlusions and frequently associated superficial thrombophlebitis. Upper extremity involvement occurs in a substantial proportion of affected patients, manifesting as digital ischemia and tissue loss. Diagnosis relies on clinical criteria (young smoker, distal ischemia, exclusion of autoimmune diseases) and angiographic findings of corkscrew collaterals. Management mandates absolute smoking cessation, as no other therapy prevents progression. While revascularization is often challenging due to the distal nature of the disease, endovascular angioplasty has emerged as a feasible option for patients with chronic limb-threatening ischemia (CLTI), showing reasonable early and late outcomes in systematic reviews . Sympathectomy or iloprost may also provide symptomatic relief in select cases .

Raynaud phenomenon: diagnostic approach and evidence-based therapy

The diagnostic approach to Raynaud phenomenon begins with differentiation between primary and secondary forms. Nailfold capillaroscopy and autoantibody screening should be performed when clinical features suggest secondary causes. Initial management emphasizes nonpharmacologic measures including cold avoidance and smoking cessation, which are recommended for all patients. First-line pharmacotherapy consists of dihydropyridine calcium channel blockers such as amlodipine or nifedipine. For refractory cases, adjunctive therapies include topical nitrates, phosphodiesterase-5 inhibitors, and in highly selected cases, botulinum toxin injection. Digital sympathectomy has a limited role and should be reserved for severe refractory ischemia unresponsive to medical therapy. Digital photoplethysmography with cold challenge testing may provide supportive diagnostic information .

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