eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Vascular Occlusive Syndromes of the Upper Extremity: Differential Diagnoses & Workup

Author: Arian Mowlavi, MD, FACS, Consulting Staff, Department of Plastic Surgery, Cosmetic Surgery Clinics of Laguna Beach
Coauthor(s): Bradon J Wilhelmi, MD, Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Jan 19, 2010

Differential Diagnoses

Thromboembolism

Other Problems to Be Considered

Arteriovenous Fistulas
Buerger Disease (Thromboangiitis Obliterans)
Churg-Strauss Disease
Churg-Strauss Syndrome (Allergic Granulomatosis)
CREST Syndrome
Giant Cell Arteritis
Raynaud Phenomenon
Scleroderma
Takayasu Arteritis
Thoracic Outlet Syndrome
Upper Extremity Occlusive Disease
Wegener Granulomatosis

Workup

Imaging Studies

  • Handheld Doppler ultrasound is used to analyze variation in the pulse waveform by reflections of sound generated by intraluminal moving red blood cells. The loudness and pitch of the audible signal is determined by the intraluminal flow. This modality allows for delineation of venous versus arterial pulses.
    • B-mode Doppler ultrasound allows for evaluation of pulsatile flow, which is depicted by a triphasic flow, involving an initial systolic upstroke followed immediately by a transient downstroke flow reversal and finally a minor upstroke elastic recoil.
    • Various monophasic patterns allow differentiation of stenosis versus occlusion of vessels.
  • Digital plethysmography allows for assessment of digital volume changes over time. Serial patterns of digital volume changes can be used to differentiate vasospastic from vaso-occlusive disease. Qualified vascular technicians are required for these discriminating analyses. Segmental arterial pressures are obtained by comparing the digital brachial index (DBI) and/or radial brachial index (RBI)–ulnar brachial index (UBI) pressures to the brachial artery pressure. Specifically, DBI or RBI ratios less than 0.7 indicate inadequate blood perfusion of end organs and encourage intervention. Digital plethysmography is a valuable and reliable tool to assess the severity of vasospasm, isolated or as part of a combined occlusive/vasospastic disorder, such as in scleroderma. The technique is also particularly valuable as a tool to objectify cold-induced vasospasm in vibration-induced white finger syndrome (VWFS) secondary to chronic hand vibrations.
  • Color duplex images are useful for evaluation of masses and used for differentiating ganglia, aneurysms, and pseudoaneurysms.
  • Radionuclide imaging can be used to obtain a 2-dimensional assessment of the vascular anatomy, as well as to ascertain temporal patterns of perfusion.
    • A radionuclide, such as technetium-99m pertechnetate, is injected intravenously, and 3 serial images are taken. The first image is similar to an angiogram, the second image involves serial pictures obtained over a 1.5-minute period that are used to assess blood pooling and flow dynamics, and finally, the third phase mimics a bone scan.
    • This modality allows for evaluation of vaso-occlusive diseases, such as aneurysms, as well as vasospastic diseases.
    • Recently, this modality has been used as a prognostic test for determining extent of frostbite injury or even degree of tissue viability following electrical injury. Absence or presence, including delay, of radiotracer in zones distal to occluded vessels allows for evaluation of the severity of the occlusion.
  • Vital capillaroscopy is a noninvasive modality used to assess integrity of nutritional papillary capillaries.
    • Using epillumination microscopic technique and specialized computer manipulations, qualitative and quantitative information can be obtained about the status of these terminal vessels.
    • Currently, no other diagnostic tool is capable of providing assessment of these microvessels.4,5
  • High-resolution magnetic resonance angiography (MRA) allows for visualization of arterial and venous structures. The advantage of MRA is that it allows for vivid images without need for arterial vascular access and without patient exposure to ionizing radiation or potentially allergy-inducing contrast dyes.
  • Finally, contrast angiography remains the criterion standard, most accurately revealing detailed vascular anatomic information. With computer manipulation, it is possible to evaluate flow direction, source of collateral flow, degree of retrograde filling, and even venous outflow. Relative indications for arteriography include suspicion of partial arterial injury resulting in an intimal flap, proximal traction injury, distal vessel occlusion caused by embolic showering, and pseudoaneurysm formation.
    • Despite its obvious advantages, this modality is used sparingly because it is costly and associated with various complications.
    • Complications can include arterial wall injury, local vasospasm, distal embolic showering, and contrast-induced allergic reaction.
  • In general, the various discussed modalities provide the clinician with further evidence of vascular pathology, especially when patients are evaluated with and without vascular stressors. In fact, most clinicians recommend completion of vascular studies before, during, and after controlled exposure to stressors, such as thermal variation, induced anoxia, or emotional lability.

Other Tests

  • Skin surface temperatures can be used to estimate digital perfusion. This modality, however, is only reliable within physiologic temperatures ranging from 20-30°C. Its primary value is to assess the efficacy of stellate ganglion block to enhance digital perfusion as a preoperative indication of the potential value of digital sympathectomy. An increase of more than 1 or 2°C suggests an ischemia-related condition, as seen with scleroderma and Raynaud disease, that could potentially be improved.

More on Vascular Occlusive Syndromes of the Upper Extremity

Overview: Vascular Occlusive Syndromes of the Upper Extremity
Differential Diagnoses & Workup: Vascular Occlusive Syndromes of the Upper Extremity
Treatment & Medication: Vascular Occlusive Syndromes of the Upper Extremity
Follow-up: Vascular Occlusive Syndromes of the Upper Extremity
References
Further Reading
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Keywords

vascular disorders, vascular compromise, vasospastic disorders, vascular insufficiency, hypothenar hammer syndrome, chronic vascular occlusive disease, thoracic outlet syndrome, embolism, Raynaud disease, Raynaud's disease, Raynaud syndrome, Raynaud's syndrome, Raynaud phenomenon, Raynaud's phenomenon, peripheral vasculitis, Wegener granulomatosis, Wegener's granulomatosis, Churg-Strauss syndrome, Takayasu vasculitis, Buerger disease, Buerger's disease, thromboangiitis obliterans, giant cell arteritis, aneurysm, pseudoaneurysm, CREST syndrome

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Contributor Information and Disclosures

Author

Arian Mowlavi, MD, FACS, Consulting Staff, Department of Plastic Surgery, Cosmetic Surgery Clinics of Laguna Beach
Arian Mowlavi, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Bradon J Wilhelmi, MD, Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine
Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association for Surgical Education, Plastic Surgery Research Council, and Wound Healing Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph E Sheppard, MD, Associate Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare
Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Clinical Orthopaedic Society, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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