eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Vascular Occlusive Syndromes of the Upper Extremity

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

Introduction

Background

Although upper extremity vascular disorders are less common than lower extremity disorders, upper extremity vascular disorders affect approximately 10% of the population. Causes of vascular compromise include acute trauma; chronic conditions, such as repetitive microtrauma; and systemic diseases involving metabolic processes, autoimmune processes, or both. General symptoms following vascular compromise include dysesthesias, paresthesias, pallor, cold intolerance, and ulceration that is associated with necrosis. The vascular system plays the critical role of delivering nutrients and clearing metabolic waste products from peripheral tissues, as well as maintaining systemic core temperature. Vascular flow is controlled by various processes, including vessel anatomy; vascular tone, which is controlled by neuroendocrine hormones along with autonomic nervous influence; and end-organ metabolic requirements. Unfortunately, vascular competence can often become compromised, leading to various disease pathologies.

Recent studies

Jones et al measured the resolution rates and factors associated with upper extremity catheter-associated deep venous thrombosis (DVT). They found that more than 50% of the DVTs resolved within 113 days when the catheter was removed 48 hours or less after diagnosis. Thrombosis resolved in only 25% of patients when the catheter was not removed. In multivariate analysis, only catheter removal predicted the likelihood of thrombus resolution (odds ratio, 3.25; 95% confidence interval, 1.16-9.09; P = .025). They noted that new-site catheter placement has a high rate of new associated DVT and that anticoagulation does not seem to increase resolution of catheter-related DVT in the upper extremities.¹

Kim et al reported on traumatic brachial artery injuries and risk factors for the development of upper extremity compartment syndrome. The investigators found that the risk of compartment syndrome was increased in cases of combined arterial injuries, combined nerve injuries, motor deficits, fractures, and increased intraoperative blood loss. Multivariate logistic regression showed that elevated intraoperative blood loss, combined arterial injury, and open fracture were independent risk factors for the development of compartment syndrome (OR 1.12, 5.79, and 2.68, respectively).²

White et al reviewed the use of multidetector computed tomographic angiography (MDCTA) in the evaluation of combat casualties with vascular injuries. They found that MDCTA yielded high-resolution images useful in delayed evaluation of vascular injuries and that the presence of metallic fragments or orthopedic hardware did not significantly interfere with MDCTA. Fifteen studies were of the lower extremities, 4 of the upper extremities, and 2 of the neck. The investigators concluded that MDCTA is a reliable and promising alternative to traditional arteriography for evaluating clinically occult vascular trauma.³

Pathophysiology

Multiple factors determine vascular flow. These include environmental events, metabolic demands, sympathetic nervous tone, and local and circulating humoral mediators. Vasoconstriction can result from increased sympathetic tone or alpha-adrenergic–stimulating humoral mediators, such as norepinephrine. In contrast, vasodilation may be prompted by parasympathetic tone (inhibiting the sympathetic tone), release of nitric oxide by endothelial cells, or myogenic autoregulatory mediators arising from increased cellular waste products, such as adenosine.

Investigators' most recent interest has surrounded the effect of endothelium on vascular tone, because of its capacity to produce 2 competing molecules: nitric oxide, a vasodilatory, endothelium-derived relaxing factor, and endothelin, a potent vasoconstrictor. Sympathetic nerves typically penetrate the arterial and venous walls, affecting the muscularis component at frequent intervals. These nerves travel variable distances in peripheral nerves prior to entering the perivascular adventitia.

In vasospastic disorders, abnormal vascular control can arise from abnormal receptor expression or from response to agonists, abnormal levels of local humoral mediators, aberrant myogenic and metabolic control mechanisms, and overwhelming sympathetic tone. In contrast, vascular insufficiency may result from physical trauma to vessels, with resulting transection or thrombotic or embolic sequelae.

Ultimate interstitial flow is determined by the pressure gradient across a single vascular lumen, as well as the total (potential) capacity of the arteriolar-capillary-venular bed. Vasospasm, which is observed in hypothenar hammer syndrome and Raynaud disease, may cause pressure gradients to fall below critical levels without affecting the total capacity of the vascular bed. In contrast, peripheral occlusive diseases, such as those seen in scleroderma, impede the pressure gradient as well as the total potential capacity of the vascular bed. This distinction is important because it affects indications for treatment and prognosis after surgery or other interventions.
 
Environmental factors, such as external toxins and ambient temperatures, affect vascular patency. This is of interest because the interaction between the external environment and the internal autonomic system has dynamic interplay. For example, for a period following digit replantation, the external temperature may affect inflow pressures at the amputation site but will not affect the vessels of the amputated part, since the sympathetic system of the adventitia will have been disrupted.

Relevant anatomy

In most patients, the dominant blood supply to the hand is provided by the superficial palmar arch, a continuation of the ulnar artery, and less so by the deep palmar arch, a continuation of the radial artery. Minor blood supply to the hand is provided for by intraosseous channels via the radial and ulnar bones, as well as by the median artery, which is present in a minority of patients. In approximately 80% of patients, the deep and superficial palmar arches are connected and are referred to as complete. This results in a dual perfusion supply to the common and proper digital vessels. This is an important attribute of hand vascular architecture, providing collateral blood flow in the event of vascular pathology affecting one of these palmar arches.

The vascular supply to the thumb is unique and includes sources directly from the radial artery and from the deep and superficial arch. In addition to its direct supply, the radial artery gives rise to a large dorsal artery, which passes distally to supply the thumb. The palmar blood supply to the thumb is provided by the princeps pollicis artery, which is derived from the first palmar metacarpal artery, the deep arch, the wrist dorsal metacarpal artery, or a terminal branch of the superficial palmar arch. The 4 terminal arteries to the thumb are the ulnar and radial palmar arteries and the ulnar and radial dorsal arteries. Vessels have been categorized arbitrarily based on their diameter and include macrovessels measuring 100 micrometers or greater in diameter versus microvessels measuring less than 100 micrometers.

Human skin provides the termination of the microcirculation, composed of nutritional papillary capillary beds, as well as nonnutritional thermoregulatory vessels. Interestingly, in normal physiology, 80-90% of microcirculation passes only through thermoregulatory vessels.

Frequency

United States

Upper extremity vascular disorders affect approximately 10% of the population.

Mortality/Morbidity

General symptoms following vascular compromise include dysesthesias, paresthesias, pallor, cold intolerance, ulceration, and tissue necrosis. Vascular competence can often become compromised, leading to various disease pathologies.

Race

No current findings identify any one race as having a particular propensity for developing vascular occlusive syndromes.

Sex

See Treatment, Medical Care. The onset of vascular occlusive disorders is affected by the sex of the patient. For example, Raynaud disease affects women aged 30-50 years. In contrast, males are affected in a bimodal fashion. Acute traumatic vascular disorders are more common in younger males because of the high incidence of motor vehicle accidents in this age group. In contrast, repetitive traumatic vascular disorders occur most often in middle-aged males who are employed in manual-type labor. In the latter case, the labor engaged in usually involves handheld vibrating tools that cause chronic trauma.

Age

See Treatment, Medical Care. Patient age also determines propensity for vascular occlusive disorders. As mentioned above, Raynaud disease affects women aged 30-50 years. Males have a bimodal affliction, with young males (because of the high incidence of motor vehicle accidents among them) most often suffering acute traumatic vascular disorders and middle-aged males (specifically, those involved in manual-type work) being most frequently affected by repetitive traumatic vascular disorders.

Clinical

History

Patient evaluation for suspected vascular pathology should include the eliciting of detailed descriptions of the trauma mechanism (penetrating or nonpenetrating), exposure to repetitive insults, the history of familial or blood disorders, drug or tobacco use, and any concurrent illness.

• Patients with insidious vascular compromise may initially report numbness, increased pain, or cold sensitivity.
• As vascular insufficiency progresses, patients may report weakness or even present with frank gangrene resulting from tissue necrosis.

Physical

A complete physical examination of the entire upper extremity and neck is warranted.

• The following must be documented: capillary refill; skin turgor; signs of infection; tissue compromise, such as ulceration or gangrene; and quality of pulses.
• Presence of masses, bruits, or both masses and bruits should be noted.
• An Allen test should be performed to differentially evaluate the patency of the ulnar and radial arteries at the distal forearm. Documenting time-to-refilling is valuable for serial examinations.
• Additionally, several diagnostic evaluations may be completed to confirm suspected diagnoses (see Workup, Imaging Studies).

Causes

Causes of vascular compromise include acute trauma; chronic modalities, such as repetitive microtrauma; and systemic disease processes involving metabolic and/or autoimmune processes. See Treatment, Medical Care for a more in-depth discussion.

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