Upper-Extremity Arterial Disease, Hand Ischemia, Raynaud/Buerger Interface, and Repetitive Injury

44.1Definition and clinical presentation

Upper-extremity arterial disease encompasses proximal atherosclerotic occlusive disease, distal vasospasm, inflammatory distal-vessel disease, repetitive-trauma arteriopathy, and traumatic arterial injury Mazzolai et al. (2024). For compression-related disease, the neurogenic, venous, and arterial pathways are distinguished in Chapter 45: Thoracic Outlet Syndromes. Presenting features govern the diagnostic and therapeutic approach:

• Bilateral digital vasospasm suggests primary Raynaud phenomenon.
• Vasospasm with multiple digital ulcers indicates secondary Raynaud phenomenon, often associated with systemic sclerosis.
• Unilateral hand ischemia with hypothenar trauma points to hypothenar hammer syndrome.
• Ischemia with occupational vibratory exposure suggests hand-arm vibration syndrome.
• Distal ischemia in young tobacco users indicates thromboangiitis obliterans (Buerger disease).
• Sudden embolic or thrombotic limb threat presents as acute limb ischemia.

44.2Diagnosis and evaluation

Diagnostic evaluation isolates the anatomic level and identifies the mechanism of ischemia. For suspected hypothenar hammer syndrome, the modified Allen test serves as a bedside screening tool; delayed or absent palmar refill on ulnar release indicates ulnar artery and superficial palmar arch occlusion Ablett 2008. Duplex ultrasonography paired with catheter or computed tomography angiography confirms the diagnosis by demonstrating segmental ulnar artery occlusion, corkscrew morphology, or focal aneurysmal dilation at the hook of the hamate St-Pierre 2019.

Hand-arm vibration syndrome assessment requires verification of exposure-response thresholds and individual host risk factors, supplemented by modality-specific imaging such as Tc-99m hand perfusion scintigraphy HAVS Risk IPD 2025 · Nilsson 2017 · HAVS Exposure 2026 · Tc99m Scintigraphy 2022. In thromboangiitis obliterans, intravenous iloprost response is quantifiable using computed tomography perfusion imaging to demonstrate distal flow changes Iloprost CT 2026. Because visceral involvement occurs in thromboangiitis obliterans, broader evaluation is required when symptoms extend beyond the extremity Fakour et al. (2019).

44.3Management and revascularization thresholds

Upper-extremity arterial management requires primary and secondary prevention tailored to the disease mechanism, with targeted revascularization reserved for threatened tissue or severe lifestyle-limiting symptoms. The treatment logic prioritizes medical and risk-factor modification before procedural intervention.

Management of upper-extremity ischemia follows a mechanism-specific stepwise algorithm:

1. Confirm the disease mechanism and treat systemic risk factors: establish single antiplatelet therapy for atherosclerotic disease, mandate complete smoking cessation for Buerger disease, and initiate core warming and cold avoidance for vasospastic disease.
2. Escalate by mechanism: use calcium-channel blockers for Raynaud attacks. For systemic-sclerosis Raynaud attacks, consider PDE5 inhibition; intravenous iloprost is an option for severe attacks after oral therapy fails. For systemic-sclerosis digital ulcers, consider PDE5 inhibition and/or intravenous iloprost. Bosentan reduces new ulcers but is not a proven treatment for healing established lesions EULAR 2023 · Matucci-Cerinic 2011.
3. Evaluate anatomical suitability for intervention: reserve open or endovascular revascularization for severe atherosclerotic symptoms, aneurysmal degeneration in hypothenar hammer syndrome, or tissue loss.
4. Identify acute trauma or acute limb threat: abandon the elective algorithm for immediate operative repair, bypass grafting, or endovascular recanalization based on the specific injury pattern rather than standard atherosclerotic protocols.

44.4Raynaud phenomenon and digital ulcers

Primary Raynaud phenomenon is a highly prevalent clinical phenotype rather than a diagnosis of exclusion Garner 2014. Foundational management requires core warming, smoking cessation, avoidance of cold exposure, and the minimization of vasoconstrictor medications before pharmacologic escalation Duong 2021. For persistent primary Raynaud symptoms despite warming and cold avoidance, a dihydropyridine calcium-channel blocker, such as nifedipine, is first-line drug therapy; trial evidence shows a modest reduction in attack frequency rather than reliable elimination of attacks Ennis 2016. For systemic-sclerosis-associated Raynaud phenomenon, EULAR retains oral nifedipine as first-line treatment and also supports considering phosphodiesterase-5 inhibitors. Intravenous iloprost is an option for severe disease after oral therapy fails; phosphodiesterase-5 inhibitors and/or intravenous iloprost should be considered for systemic-sclerosis digital ulcers EULAR 2023.

In patients with systemic sclerosis and a history of multiple digital ulcers, the endothelin-receptor antagonist bosentan reduces the development of new digital ulcers, based on the RAPIDS-1 and RAPIDS-2 trials Ross 2023. Dose bosentan 62.5 mg twice daily for 4 weeks, then 125 mg twice daily. In RAPIDS-2 it cut the mean number of new digital ulcers over 24 weeks by roughly 30% (1.9 versus 2.7, p=0.04) but did not improve healing of established ulcers Matucci-Cerinic 2011. Monitor liver enzymes monthly. Vasospastic attacks, systemic-sclerosis ulcers, Buerger disease, and atherosclerotic upper-limb obstruction require different drug strategies. Aspirin and statins should not be prescribed automatically for isolated Raynaud phenomenon or Buerger disease on the basis of a PAD guideline; assess any separate atherosclerotic cardiovascular indication Buerger Cochrane 2020 · Ennis 2016.

44.5Buerger disease (thromboangiitis obliterans)

Thromboangiitis obliterans is a tobacco-linked distal ischemic disease in which complete tobacco abstinence is the primary limb-preservation intervention. In a retrospective multicenter cohort of 224 patients, vascular events occurred in 58.9% and amputations in 21.4% over a mean 5.7 years; estimated amputation-free survival was 66% at 15 years. Tobacco cessation was associated with a lower amputation risk Thromboangiitis Outcomes 2018. For severe ischemic rest pain or ulceration, intravenous iloprost is a possible adjunct to tobacco abstinence. The 2020 Cochrane review found moderate-certainty evidence of better ulcer healing and rest-pain relief than aspirin after 28 days, but no clear reduction in amputations at six months. Oral iloprost did not show the same benefit. These trials principally concerned critical leg ischemia, not isolated hand disease. They do not establish aspirin, statins, calcium-channel blockers, or bosentan as disease-modifying treatment for Buerger disease; use treatment for coexisting atherosclerosis or vasospasm on its own indication Buerger Cochrane 2020.

44.6Occupational and repetitive trauma

Repetitive occupational exposure drives both hand-arm vibration syndrome and hypothenar hammer syndrome. Hand-arm vibration exposure correlates with distinct vascular and neurologic disease outcomes Nilsson 2017. Persistent vibration exposure with vascular symptoms necessitates direct occupational exposure reduction and monitoring, as the risk is shaped by cumulative dose and individual susceptibility HAVS Risk IPD 2025 · HAVS Exposure 2026. Hypothenar hammer syndrome requires identification of ulnar artery damage at the hook of the hamate, with intervention directed by the degree of occlusion or aneurysmal change rather than generalized vasodilator therapy St-Pierre 2019.

44.7Areas of controversy

Device selection for subclavian artery stenosis lacks comparative trial data; there are no completed or ongoing randomized controlled trials comparing angioplasty to stenting Iared 2022. While contemporary cohort data signal effective outcomes for primary covered-stent implantation in supra-aortic arch and subclavian occlusive disease, randomized superiority remains unproven Supra-aortic Stent 2026.

For hypothenar hammer syndrome presenting with acute or subacute occlusion, evidence for endovascular thrombolysis is restricted to small retrospective series and case reports, limited by selection bias and heterogeneity in lytic agent, dose, and duration HHS Thrombolysis · 2021. In refractory Raynaud phenomenon, botulinum toxin A injection is an emerging procedural modality; its evidence base remains confined to narrative reviews and case series distinct from established vasodilator trials Botulinum Raynaud 2026.

Further reading

• Systemic pharmacological treatment of digital ulcers in systemic sclerosis: a systematic literature review. (2023). Systemic-sclerosis digital-ulcer drug evidence. Ross 2023
• Endovascular Thrombolysis in Hypothenar Hammer Syndrome: A Systematic Review. (2021). Hypothenar hammer syndrome thrombolysis evidence; selected reports do not prove comparative efficacy. HHS Thrombolysis · 2021