Chapter 33: Chronic Upper Extremity Ischemia

INTRODUCTION

Chronic limb-threatening ischemia in the upper extremity, and in particular, chronic hand ischemia is relatively unusual and arterial occlusions are often an incidental finding on physical, ultrasonic, or arteriographic examination.¹ The presence of rich collateral networks, small muscle mass, and ease of adaptation of activity of the upper extremity mitigates against symptomatic disease. For management purposes of, occlusive disease of the upper limb arteries can be classified as above-the-elbow arteries (innominate, subclavian, axillary, and humeral) or below-the-elbow arteries (radial, ulnar, interosseous, and hand arteries).^2,3 Compared with lower extremity ischemia, direct reconstruction of upper extremity arterial occlusive disease constitutes less than 4% of all vascular bypass procedures and as a result, there is limited data available on outcomes.^4,5 It has been estimated that only 5% of patients with limb ischemia have symptomatic involvement of the upper extremity.⁶ Chronic critical ischemia of the hand due to atherosclerotic disease is rare but is a disabling condition.¹ Below elbow disease is a frequent problem in diabetics mirroring the problem in the lower extremities. The majority of the literature on digital ischemia has concentrated on nonatherosclerotic occlusive disease of the hand. Porter and Taylor⁷ demonstrated that small arterial occlusive disease of the palmar and digital arteries due to diverse causes, is a frequent cause of upper extremity ischemia.

PATHOLOGY

Several disease processes involve the upper extremity and many are shared with the lower extremity.

• Atherosclerosis: Atherosclerotic occlusive disease is common etiology of above elbow disease⁸ and most commonly presents with arm claudication or distal embolism. Its most common location is in the proximal subclavian artery.

• Diabetes: The increasing incidence of diabetes mellitus is leading to an increasing prevalence of below elbow disease and increasing small vessel disease of the hand.⁹ This has led to more common presentations with armrest pain and/or distal gangrene. Its most common location is in the distal radial and ulnar arteries and the metacarpal and digital arteries of the hand.

• Vasculitides: Giant cell arteritis of the arm is referred to as large vessel vasculitis and patients with predominant large vessel vasculitis are usually affected at a younger age and often have nonspecific manifestations such as constitutional syndrome, fever of unknown origin, or refractory/atypical polymyalgia rheumatica.¹⁰ The condition is seen in the above elbow vasculature and leads to claudication or rest pain.

• Autoimmune digital diseases: Ischemic finger ulceration due to digital occlusive disease has an autoimmune disease etiology in 54% of cases: hypersensitivity angiitis in 22%, Buerger’s disease in 9%, arteriosclerosis obliterans in 9%, and miscellaneous diseases in remaining 6%.^11,12

• Chronic thromboembolism: An upstream source of intermittent but continuous athero-embolism to the forearm and hand is recognized as a contributing pathology to hand ischemia and arm claudication. These situations require treatment of the culprit lesion in addition to the treatment of the presenting hand issues.

Differential Diagnosis