Noninvasive diagnosis of upper extremity vascular disease

Symptomatic arterial disease of the upper extremity is uncommon and accounts for approximately 5% of all cases of extremity ischemia. Unlike the lower extremity, where atherosclerosis is by far the most common disorder, ischemia in the upper extremity may be caused by a variety of systemic diseases. The diagnosis of upper extremity arterial disease is often complex and requires a complete history and physical examination, laboratory screening, and noninvasive and possibly invasive examination of the arteries of the upper extremity. In contrast to lower extremity ischemia, surgical intervention is rarely required in patients with upper extremity ischemia and the diagnosis of upper extremity ischemia can often be sufficiently accomplished using only noninvasive diagnostic tests.We have had a long-standing interest in upper extremity ischemia at the Oregon Health & Science University and over the past 30 years have evaluated over 1500 patients. Our noninvasive testing includes segmental arm pressures, digital pressures and arterial waveforms using photoplethysmography (PPG), and testing for cold-induced vasospasm. Duplex evaluation plays a minor role, and arteriography is rarely employed. The noninvasive tests, in combination with the history and physical examination, generally give all the necessary information to secure the diagnosis and guide the treatment for upper extremity ischemia. In this chapter, we will review the disease processes that result in upper extremity ischemia and our diagnostic approach to patients presenting with it.