link
Bookmarks
Upper Extremity Arteries: Exclusion
Zubin Irani, MD; T. Gregory Walker, MD, FSIR
To access 4,300 diagnoses written by the world's leading experts in radiology, please log in or subscribe.Log inSubscribe

KEY FACTS

  • Terminology

    • Procedure

      • Outcomes

        TERMINOLOGY

        • Definitions

          • Axillary artery aneurysm: Localized arterial dilatation ≥ 50% compared with normal diameter; may be true aneurysm or pseudoaneurysm
            • Pseudoaneurysms constitute majority of cases
              • Usually due to penetrating or iatrogenic trauma
              • May occur in association with blunt trauma
                • Humeral fracture, anterior shoulder dislocation
              • May also be due to postobstructive lesions in patients with thoracic outlet syndrome
              • Less frequently due to congenital arterial defects, infection, or vasculitis/vasculopathy
            • True aneurysms relatively rare
              • May occur with repetitive blunt trauma
                • Classically due to long-term crutch use
            • Major morbidity if unrecognized/untreated
              • Aneurysm/pseudoaneurysm rupture
              • Distal thromboembolism with ischemia
              • Brachial plexus compression; sensorimotor loss
          • Brachial artery aneurysm: Same diameter criterion of ≥ 50% dilatation compared with normal diameter; may be true aneurysm or pseudoaneurysm
            • Pseudoaneurysms constitute majority of cases
              • Usually due to penetrating or iatrogenic trauma
                • Includes inadvertent arterial injection in IV drug abusers; can cause mycotic pseudoaneurysm
              • May occur in association with blunt trauma
                • Mid to distal humeral fracture
            • True aneurysms extremely rare
              • Most commonly related to repetitive blunt trauma
            • Major morbidity if unrecognized/untreated
              • Aneurysm rupture uncommon
              • Distal thromboembolism with ischemia may occur
                • 33% of asymptomatic lesions later become symptomatic
              • Pain/paraesthesia from median nerve compression
          • Thoracic outlet syndrome: Clinical disorder caused by extrinsic compression of neurovascular structures exiting or entering thorax
            • May be predominantly neurogenic, venous or arterial
              • Symptoms from arterial compression in < 5%
                • Pain, coolness, pallor, diminished pulses
                • May have distal thromboembolic complications (e.g., cyanosis, digital ulceration, ischemia)
              • Clinical symptoms involve compression of brachial plexus/related nerves in > 90%
                • Pain, numbness, tingling, hand weakness
              • Various imaging manifestations of arterial thoracic outlet syndrome
                • Aneurysm ± mural thrombus
                • Arterial compression in costoclavicular space
                • Arterial thrombosis
                • Distal embolization/occlusion
                • Stenosis with poststenotic dilatation
          • Vascular laceration: Complete/incomplete arterial transection
            • Most often due to penetrating or iatrogenic trauma
            • Clinical manifestations
              • Pulsatile bleeding or expanding hematoma
              • Absent distal pulses with cold, pale limb
              • Palpable thrill or audible bruit
            • Various imaging manifestations
              • Active contrast extravasation
                • May be due to partial arterial disruption or complete arterial transection
              • Formation of traumatic arteriovenous fistula
              • Pseudoaneurysm formation
        • Pertinent Vascular Anatomy

          • Axillary artery: Originates at lateral margin of 1st rib; has 3 segments based on relationship to superficially located pectoralis minor muscle
            • 1st segment: Portion medial to pectoralis minor
              • Superior thoracic artery: Supplies 1st & 2nd intercostal spaces, upper serratus anterior
            • 2nd segment: Portion behind pectoralis minor
              • Thoracoacromial artery: Supplies pectoral and deltoid muscles; extends to clavicle/acromion
              • Lateral thoracic (external mammary) artery: Supplies serratus anterior & pectoralis major muscles, lateral structures of thorax/breast
            • 3rd segment: Portion lateral to pectoralis minor
              • Subscapular artery (largest branch of axillary artery): Supplies subscapularis muscle
              • Anterior circumflex humeral artery: Supplies humeral head, shoulder joint, upper biceps muscles
              • Posterior circumflex humeral artery: Supplies teres minor & deltoid muscles
          • Brachial artery: Continuation of axillary artery beyond lower margin of teres minor muscle; divides into radial & ulnar arteries at antecubital fossa
            • Radial artery: Main artery of lateral forearm
              • Landmark for division between anterior and posterior compartments of forearm
              • Yields superficial palmar branch, which joins superficial palmar arch
              • Terminates in deep palmar arch, which joins with deep branch of ulnar artery
                • Deep palmar arch located more proximally
              • Supplies thumb (princeps pollicis artery), 2nd digit
            • Ulnar artery: Main artery of medial forearm
              • Typically larger than radial artery
              • Yields interosseous artery below radial tuberosity
                • Supplies deep anterior & posterior forearm
              • Distally divides into deep & superficial branches
              • Terminates in superficial palmar arch, which joins with superficial branch of radial artery
                • Superficial palmar arch located more distally
              • Supplies 4th & 5th digits; variable supply to 3rd

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        • Things to Avoid

                          OUTCOMES

                          • Problems

                            • Complications

                              • Expected Outcome

                                Selected References

                                1. Thai JN et al: Evidence-based comprehensive approach to forearm arterial laceration. West J Emerg Med. 16(7):1127-34, 2015
                                2. Bozlar U et al: CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients. AJR Am J Roentgenol. 201(4):753-63, 2013
                                3. Bozlar U et al: CT angiography of the upper extremity arterial system: Part 1-Anatomy, technique, and use in trauma patients. AJR Am J Roentgenol. 201(4):745-52, 2013
                                4. Jens S et al: Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 46(3):329-37, 2013
                                5. Ikeda N et al: Combined endovascular and open surgical approach for the management of subclavian artery occlusion due to thoracic outlet syndrome. J Card Surg. 26(3):309-12, 2011
                                6. Bucci F et al: Successful embolization of a suprascapular artery aneurysm. Ann Vasc Surg. Epub ahead of print, 2011
                                7. Brooke BS et al: Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol. 25(6):535-40, 2010
                                8. Criado E et al: The spectrum of arterial compression at the thoracic outlet. J Vasc Surg. 52(2):406-11, 2010
                                9. Troutman DA et al: Open repair and endovascular covered stent placement in the management of bilateral axillary artery aneurysms. Vasc Endovascular Surg. 44(8):708-9, 2010
                                10. Tan KK et al: Surgical management of infected pseudoaneurysms in intravenous drug abusers: single institution experience and a proposed algorithm. World J Surg. 33(9):1830-5, 2009
                                11. Danetz JS et al: Feasibility of endovascular repair in penetrating axillosubclavian injuries: a retrospective review. J Vasc Surg. 41(2):246-54, 2005
                                12. Schunn CD et al: Brachial arteriomegaly and true aneurysmal degeneration: case report and literature review. Vasc Med. 7(1):25-7, 2002
                                13. Hilfiker PR et al: Stent-graft therapy for subclavian artery aneurysms and fistulas: single-center mid-term results. J Vasc Interv Radiol. 11(5):578-84, 2000
                                14. Gray RJ et al: Management of true aneurysms distal to the axillary artery. J Vasc Surg. 28(4):606-10, 1998
                                15. Clark ET et al: True aneurysmal disease in the hand and upper extremity. Ann Vasc Surg. 5(3):276-81, 1991
                                Related Anatomy
                                Loading...
                                Related Differential Diagnoses
                                Loading...
                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Procedure

                                    • Outcomes

                                      TERMINOLOGY

                                      • Definitions

                                        • Axillary artery aneurysm: Localized arterial dilatation ≥ 50% compared with normal diameter; may be true aneurysm or pseudoaneurysm
                                          • Pseudoaneurysms constitute majority of cases
                                            • Usually due to penetrating or iatrogenic trauma
                                            • May occur in association with blunt trauma
                                              • Humeral fracture, anterior shoulder dislocation
                                            • May also be due to postobstructive lesions in patients with thoracic outlet syndrome
                                            • Less frequently due to congenital arterial defects, infection, or vasculitis/vasculopathy
                                          • True aneurysms relatively rare
                                            • May occur with repetitive blunt trauma
                                              • Classically due to long-term crutch use
                                          • Major morbidity if unrecognized/untreated
                                            • Aneurysm/pseudoaneurysm rupture
                                            • Distal thromboembolism with ischemia
                                            • Brachial plexus compression; sensorimotor loss
                                        • Brachial artery aneurysm: Same diameter criterion of ≥ 50% dilatation compared with normal diameter; may be true aneurysm or pseudoaneurysm
                                          • Pseudoaneurysms constitute majority of cases
                                            • Usually due to penetrating or iatrogenic trauma
                                              • Includes inadvertent arterial injection in IV drug abusers; can cause mycotic pseudoaneurysm
                                            • May occur in association with blunt trauma
                                              • Mid to distal humeral fracture
                                          • True aneurysms extremely rare
                                            • Most commonly related to repetitive blunt trauma
                                          • Major morbidity if unrecognized/untreated
                                            • Aneurysm rupture uncommon
                                            • Distal thromboembolism with ischemia may occur
                                              • 33% of asymptomatic lesions later become symptomatic
                                            • Pain/paraesthesia from median nerve compression
                                        • Thoracic outlet syndrome: Clinical disorder caused by extrinsic compression of neurovascular structures exiting or entering thorax
                                          • May be predominantly neurogenic, venous or arterial
                                            • Symptoms from arterial compression in < 5%
                                              • Pain, coolness, pallor, diminished pulses
                                              • May have distal thromboembolic complications (e.g., cyanosis, digital ulceration, ischemia)
                                            • Clinical symptoms involve compression of brachial plexus/related nerves in > 90%
                                              • Pain, numbness, tingling, hand weakness
                                            • Various imaging manifestations of arterial thoracic outlet syndrome
                                              • Aneurysm ± mural thrombus
                                              • Arterial compression in costoclavicular space
                                              • Arterial thrombosis
                                              • Distal embolization/occlusion
                                              • Stenosis with poststenotic dilatation
                                        • Vascular laceration: Complete/incomplete arterial transection
                                          • Most often due to penetrating or iatrogenic trauma
                                          • Clinical manifestations
                                            • Pulsatile bleeding or expanding hematoma
                                            • Absent distal pulses with cold, pale limb
                                            • Palpable thrill or audible bruit
                                          • Various imaging manifestations
                                            • Active contrast extravasation
                                              • May be due to partial arterial disruption or complete arterial transection
                                            • Formation of traumatic arteriovenous fistula
                                            • Pseudoaneurysm formation
                                      • Pertinent Vascular Anatomy

                                        • Axillary artery: Originates at lateral margin of 1st rib; has 3 segments based on relationship to superficially located pectoralis minor muscle
                                          • 1st segment: Portion medial to pectoralis minor
                                            • Superior thoracic artery: Supplies 1st & 2nd intercostal spaces, upper serratus anterior
                                          • 2nd segment: Portion behind pectoralis minor
                                            • Thoracoacromial artery: Supplies pectoral and deltoid muscles; extends to clavicle/acromion
                                            • Lateral thoracic (external mammary) artery: Supplies serratus anterior & pectoralis major muscles, lateral structures of thorax/breast
                                          • 3rd segment: Portion lateral to pectoralis minor
                                            • Subscapular artery (largest branch of axillary artery): Supplies subscapularis muscle
                                            • Anterior circumflex humeral artery: Supplies humeral head, shoulder joint, upper biceps muscles
                                            • Posterior circumflex humeral artery: Supplies teres minor & deltoid muscles
                                        • Brachial artery: Continuation of axillary artery beyond lower margin of teres minor muscle; divides into radial & ulnar arteries at antecubital fossa
                                          • Radial artery: Main artery of lateral forearm
                                            • Landmark for division between anterior and posterior compartments of forearm
                                            • Yields superficial palmar branch, which joins superficial palmar arch
                                            • Terminates in deep palmar arch, which joins with deep branch of ulnar artery
                                              • Deep palmar arch located more proximally
                                            • Supplies thumb (princeps pollicis artery), 2nd digit
                                          • Ulnar artery: Main artery of medial forearm
                                            • Typically larger than radial artery
                                            • Yields interosseous artery below radial tuberosity
                                              • Supplies deep anterior & posterior forearm
                                            • Distally divides into deep & superficial branches
                                            • Terminates in superficial palmar arch, which joins with superficial branch of radial artery
                                              • Superficial palmar arch located more distally
                                            • Supplies 4th & 5th digits; variable supply to 3rd

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Procedure Steps

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      • Things to Avoid

                                                        OUTCOMES

                                                        • Problems

                                                          • Complications

                                                            • Expected Outcome

                                                              Selected References

                                                              1. Thai JN et al: Evidence-based comprehensive approach to forearm arterial laceration. West J Emerg Med. 16(7):1127-34, 2015
                                                              2. Bozlar U et al: CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients. AJR Am J Roentgenol. 201(4):753-63, 2013
                                                              3. Bozlar U et al: CT angiography of the upper extremity arterial system: Part 1-Anatomy, technique, and use in trauma patients. AJR Am J Roentgenol. 201(4):745-52, 2013
                                                              4. Jens S et al: Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 46(3):329-37, 2013
                                                              5. Ikeda N et al: Combined endovascular and open surgical approach for the management of subclavian artery occlusion due to thoracic outlet syndrome. J Card Surg. 26(3):309-12, 2011
                                                              6. Bucci F et al: Successful embolization of a suprascapular artery aneurysm. Ann Vasc Surg. Epub ahead of print, 2011
                                                              7. Brooke BS et al: Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol. 25(6):535-40, 2010
                                                              8. Criado E et al: The spectrum of arterial compression at the thoracic outlet. J Vasc Surg. 52(2):406-11, 2010
                                                              9. Troutman DA et al: Open repair and endovascular covered stent placement in the management of bilateral axillary artery aneurysms. Vasc Endovascular Surg. 44(8):708-9, 2010
                                                              10. Tan KK et al: Surgical management of infected pseudoaneurysms in intravenous drug abusers: single institution experience and a proposed algorithm. World J Surg. 33(9):1830-5, 2009
                                                              11. Danetz JS et al: Feasibility of endovascular repair in penetrating axillosubclavian injuries: a retrospective review. J Vasc Surg. 41(2):246-54, 2005
                                                              12. Schunn CD et al: Brachial arteriomegaly and true aneurysmal degeneration: case report and literature review. Vasc Med. 7(1):25-7, 2002
                                                              13. Hilfiker PR et al: Stent-graft therapy for subclavian artery aneurysms and fistulas: single-center mid-term results. J Vasc Interv Radiol. 11(5):578-84, 2000
                                                              14. Gray RJ et al: Management of true aneurysms distal to the axillary artery. J Vasc Surg. 28(4):606-10, 1998
                                                              15. Clark ET et al: True aneurysmal disease in the hand and upper extremity. Ann Vasc Surg. 5(3):276-81, 1991