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Overview of upper extremity peripheral artery disease

Author
Neal R Barshes, MD, MPH, FACS
Section Editors
Denis L Clement, MD, PhD
Joseph L Mills, Sr, MD
John F Eidt, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Peripheral artery disease (PAD) of the upper extremities is common. It is most often asymptomatic but may cause exertional pains, ischemic pains, gangrene, or ulceration. Clinicians should focus on recognizing when upper extremity PAD merits treatment. Exertional pain is defined as a reproducible discomfort of a defined group of muscles induced by exercise and relieved with rest due to an imbalance between supply and demand of blood flow. The manifestations of upper extremity peripheral artery disease will be reviewed. Lower extremity peripheral artery disease is discussed in detail elsewhere. (See "Clinical features and diagnosis of lower extremity peripheral artery disease".)

UPPER EXTREMITY ARTERIAL ANATOMY

The subclavian arteries provide blood flow to the upper extremities. On the left, the subclavian artery originates directly from the aorta distal to the left common carotid artery. On the right, blood flows first through the innominate artery, which divides into the right common carotid artery and right subclavian artery. The anatomy of the aortic arch can vary (figure 1) and may include an anomalous origin of the subclavian arteries. Retroesophageal subclavian vessels may compress the esophagus causing dysphagia, but the vessel may also be compressed, leading to upper extremity ischemia. (See "Vascular rings and slings" and "Approach to the evaluation of dysphagia in adults", section on 'Cardiovascular abnormalities'.)

The vertebral arteries most often arise bilaterally as the first branch of the subclavian artery. In approximately 6 percent of patients, the vertebral artery, especially the left, may originate directly from the aortic arch [1]. The subclavian artery passes over the first rib posterior to the anterior scalene muscle (figure 2) and becomes the axillary artery at the lateral margin of the first rib. The axillary artery becomes the brachial artery (figure 3) at the lower margin of the teres major muscle. The brachial artery passes between the biceps and triceps muscles accompanied by the ulnar and median nerves adjacent to the humerus and supplies the soft tissues of the arm. In the antecubital fossa, the brachial artery divides (figure 4) into the radial, interosseus, and ulnar arteries to supply soft tissues of the forearm. Distally at the wrist, the ulnar artery and radial artery supply the hand (figure 5).

The extensive collateral circulation around the shoulder compensates well for stenoses and occlusions in the innominate, subclavian, and axillary arteries (figure 6). When the proximal subclavian artery is occluded, blood flow is maintained to the arm via connections between the superior and inferior thyroid arteries; vertebral arteries, intercostals, superior epigastric and internal thoracic arteries; profunda cervicis and descending branch of the occipital artery; scapular branches of the thyrocervical trunk and the branches of the axillary artery; and the thoracic branches of the axillary artery with the aortic intercostals [2].

PRESENTATION

Most patients with upper extremity peripheral artery disease are asymptomatic and detected only by the finding of asymmetric arm blood pressures. If a difference is identified, we repeat the blood pressure measurement in both arms to confirm the finding. (See 'Diagnosis' below.)

    
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Literature review current through: Nov 2017. | This topic last updated: Nov 22, 2017.
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