Overview

Chronic upper limb ischaemia is a form of peripheral arterial disease that results in a symptomatic reduced blood supply to the upper limb. The common symptoms are weakness, cramps, pain, and digital ischaemia/gangrene. Upper limb ischaemia occurs less frequently than lower limb ischaemia. 

Anatomy/ Physiology

Most common sites involved are subclavian, axillary and brachial artery.

Aetiology 

• Atherosclerosis
• Previous trauma
• Axillary irradiation (radiotherapy)
• Buerger’s disease
• Subclavian steal syndrome
• Takayasu’s arteritis
• Thoracic outlet syndrome
• Hypothenar hammer syndrome
• Secondary Raynaud’s (Raynaud’s phenomenon)

Risk factors

• Smoking
• Hypertension
• High cholesterol
• Diabetes
• Obesity
• Shoulder overuse (eg. swimming)
• Repetitive shoulder injuries

Pathophysiology

Progressive arterial narrowing leads to reduced perfusion, which results in chronic hypoxia. This forces the tissue to rely on anaerobic respiration and leads to build up of lactic acid that activates pain receptors. As the hypoxia worsens, the tissue slowly starts to undergo necrosis. The blood supply may be compensated by collateral vessel formation but this is not always sufficient, especially in severe occlusions or during increased demand.

Clinical manifestation

• Often asymptomatic (collaterals compensate).
• Intermittent claudication – fatigue, cramping, or pain in forearm/hand on exertion.
• Progressing to rest pain in more severe cases
• Skin changes: ulcers, gangrene, hair loss
• Cold and pale distal part of limb
• Numbness and tingling due to ischaemic nerve damage

Examination

• Absent / weak distal pulses (radial/ulnar).
• Blood pressure discrepancy between arms (>15–20 mmHg = significant)
• Bruit over subclavian/axillary artery
• Signs of collaterals (prominent shoulder/chest wall vessels)
• Cervical rib or subclavian artery palpation: ability to palpate indicates thoracic outlet syndrome

Diagnosis

Wrist-brachial index (WBI)

• Calculated by dividing the higher systolic pressure of the wrist (radial or ulnar artery) and higher of the two brachial systolic pressures
• Ratio of less than 1 indicates occlusion

Segmental blood pressure (measured at various points along the limb to help localise disease)

• A drop >10-20 mmHg between adjacent cuffs suggests arterial obstruction between those two levels.
• The site of greatest pressure drop indicates the location of significant stenosis or occlusion

Imaging:

• Cervical spine and thoracic outlet X-rays: to visualise proximal obstruction
• CT/MRI: to look for fibrous bands/ribs and stenoses/occlusions
• Arterial duplex or angiography: to diagnose proximal arterial lesions
• Duplex or venography: for subclavian vein stenosis or occlusion

Differential diagnosis 

• Cerebrovascular event – causes paresthesia and motor weakness
• Complex regional pain syndrome – presents with pain, swelling, skin changes; occurs after a fracture, soft tissue injury or surgery; pulses are normal
• Cervical radiculopathy – compression of a cervical nerve root; pain present but pulses are normal
• Carpal tunnel syndrome – median nerve compression in carpal tunnel; sensory loss but normal pulses
• Peripheral neuropathy – can be caused by diabetes, alcohol, B12 deficiency; stocking-glove pain distribution; normal pulses
• Phlegmasia cerulea dolens (rare) – extensive DVT of proximal upper limb veins

Treatment

Risk factors modification

• Smoking cessation
• Control blood pressure and glucose

Medication

• Oral statins for dyslipidemia
• Anti-platelet therapy (aspirin or clopidogrel)
• Dihydropyridine calcium channel blocker (nifedipine) – used in Raynaud’s

Endovascular treatment

• Angioplasty +/- stent
  • Ideal for short segment occlusion
  • First line when functionally limiting symptoms are present
  • Preferred in focal stenosis of subclavian and axillary artery 

Surgery

• Bypass
  • In long segment occlusions
  • If angioplasty fails
• Resection of cervical rib or anterior scalene muscle; followed by replacement of damaged segment of subclavian artery with a vein or prosthetic graft
  • Used to relieve pressure in thoracic outlet syndrome

Complications and Prognosis

Complications

• Reduced muscle strength due to chronic hypoxia
• Delayed wound healing
• Higher risk of infection due ulceration and gangrene
• Amputation (in severe cases)
• Myalgia (side effect of statins)
• Bleeding (side effect of antiplatelets)

Prognosis

• Low rate of major amputation 
• The rate of successful treatment is high

References

1. Peripheral vascular disease. In: McLatchie G, Borley N, Agarwal A, Jeyarajah S, Harries R, Weerakkody R, et al., editors. Oxford Handbook of Clinical Surgery: Oxford University Press; 2022. p. 0. https://doi.org/10.1093/med/9780198799481.003.0019 

2. Marle Jv. Upper Limb Ischaemia. The University of Cape Town General Surgery Textbook for Undergraduates.
https://vula.uct.ac.za/access/content/group/9c29ba04-b1ee-49b9-8c85 9a468b556ce2/Open%20access%20textbook%20of%20general%20surgery/content.html 

3. Shah PS, Gates JD. Overview of upper extremity ischemia. UpToDate. 2024. https://www-uptodate-com.ezproxy.newcastle.edu.au/contents/overview-of-upper-extremity-ischemia 

4. Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis. The Lancet. 2012;379(9819):905-14. https://doi.org/10.1016/S0140-6736(11)61710-8 

5. Mitchell EL. Noninvasive diagnosis of uppper and lower extremity arterial disease. UpToDate. 2024. https://www-uptodate-com.ezproxy.newcastle.edu.au/contents/noninvasive-diagnosis-of-upper-and-lower-extremity-arterial-disease 

6. Cheun TJ, Jayakumar L, Sheehan MK, Sideman MJ, Pounds LL, Davies MG. Outcomes of upper extremity interventions for chronic critical ischemia. Journal of Vascular Surgery. 2019;69(1):120-8.e2. https://doi.org/10.1016/j.jvs.2018.04.056 

7. Eskandari MK. Upper-Extremity Arterial Occlusive Disease. Medscape. 2024. https://emedicine.medscape.com/article/462289-overview#a2