10

Duplex Assessment of
Upper-­Limb Arterial Disease

OUTLINE
Introduction, 179 Palmar Arch and Digital Arteries, 184
Anatomy of the Upper-­Extremity Arteries, 179 Ultrasound Appearance, 185
Symptoms and Treatment of Upper-­Limb Arterial Normal Appearance, 185
Disease, 181 Abnormal Appearance, 185
Practical Considerations and Patient Positioning for Thoracic Outlet Syndrome, 187
Duplex Assessment of Upper-­Extremity Arterial Maneuvers for Assessing TOS, 189
Disease, 182 Duplex Assessment of TOS, 190
Scanning Techniques, 182 Aneurysms, 190
Subclavian and Axillary Arteries, 182 Other Disorders of the Upper-­Extremity
Brachial Artery, 184 Circulation, 191
Radial and Ulnar Arteries, 184 Reporting, 192

arterial access, mainly in the brachial or radial arteries.

Introduction
Microvascular disorders, such as Raynaud’s phenome-
In contrast to lower-­limb arteries, atherosclerotic dis- non, can produce significant symptoms in the hands,
ease in the upper extremities is less common and which may be confused with atherosclerotic disease.
accounts for <10% of the average vascular laboratory
workload. The most commonly affected sites are the Anatomy of the Upper-­Extremity
brachiocephalic trunk, subclavian (SA), and axillary
arteries. This is sometimes associated with extracranial
Arteries
carotid artery disease. Radiotherapy in this region can The anatomy of the upper-­extremity arteries is illus-
result in fibrosis and scarring and can also cause damage trated in Figs. 10.1 and 10.2. The left SA divides directly
to the SA and axillary arteries. Compression of the SA in from the aortic arch, but the right SA originates from
the area of the thoracic outlet, known as thoracic outlet the brachiocephalic artery. The thoracic outlet is the
syndrome (TOS), can produce significant upper-­limb point where the SA, subclavian vein, and brachial nerve
symptoms and in rare cases lead to SA aneurysms. plexus exit the chest. The SA runs between the anterior
Acute obstruction of the axillary or brachial arter- and middle scalene muscles and passes between the
ies may also occur due to embolization from the heart clavicle and first rib to become the axillary artery. The
or SA aneurysms. In this situation, duplex scanning diameter of the SA ranges from 0.7 to 1.1 cm. The SA
is useful for demonstrating the length and position of has a number of important branches, including the ver-
the occlusion. Pseudoaneurysms can occur following tebral artery and internal thoracic artery (also referred

179
180 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

Right common carotid artery Left common carotid artery 1st rib (projecting
Axillary artery Clavicle back into page)
Right vertebral artery Left subclavian artery
Subclavian
Anterior and posterior artery
Right subclavian Left vertebral artery humeral circumflex
artery arteries
Thyrocervical
trunk

Sternum

Internal Deep brachial

Brachiocephalic thoracic artery
artery artery

Brachial artery
Aortic arch

Fig. 10.1 The arterial anatomy of the aortic arch and subclavian
artery. Radial recurrent
artery Ulnar recurrent artery
to as the mammary artery), which is frequently used for
coronary artery bypass surgery.
Common interosseous
The axillary artery becomes the brachial artery as it artery
crosses the lower margin of the tendon of the teres major Radial artery Ulnar artery
muscle, at the top of the arm. The diameter of the axil-
lary artery ranges between 0.6 and 0.8 cm. The brachial
artery then runs distally on the medial or inner side Deep
of the arm in a groove between the triceps and biceps palmar arch
muscles. The deep brachial artery divides from the main
trunk of the brachial artery in the upper arm and acts
as an important collateral pathway around the elbow Superficial palmar arch
if the brachial artery is occluded distally. The brachial
artery runs in a medial to lateral course over the inner Common palmar
aspect of the elbow (cubital fossa) and then divides, 1 to Proper digital digital arteries
2 cm below the elbow, into the radial and ulnar arter- arteries
ies. However, the bifurcation can be quite variable in Fig. 10.2 The arterial anatomy of the arm and hand.
position and can sometimes be seen in the upper arm.
The ulnar artery dives deep beneath the flexor tendons
in the upper forearm before becoming superficial in the The radial artery supplies the deep palmar arch in the
mid-­forearm. The radial artery runs along the lateral hand, and the ulnar artery supplies the superficial pal-
side of the forearm toward the thumb and is palpable mar arch. There are usually communicating arteries
at the wrist. The ulnar artery runs along the medial side between the two systems. In some people only one of
of the forearm and is sometimes the dominant vessel the wrist arteries will supply a palmar arch system. The
of the forearm. The common interosseous artery is an fingers are supplied by the palmar digital arteries. There
important branch of the ulnar artery in the upper fore- are a number of anatomical variations in the arm that
arm as it can act as a collateral pathway if the radial and are shown in Table 10.1. The arms normally develop
ulnar arteries are occluded. The hand is comprised of good collateral circulation around diseased segments.
a complex vascular network formed from the branches The major collateral pathways of the arm are summa-
and distal continuations of the radial and ulnar arteries. rized in Table 10.2.
 CHAPTER 10 Duplex Assessment of Upper-­Limb Arterial Disease 181

TABLE 10.1 Anatomical Variations of the BOX 10.1 Common Causes of Symptoms

Upper-­limb Arteries Involving the Arterial and Microvascular
Circulation of the Arms and Hands
Artery Variation
Left subclavian Common origin with common • Atherosclerotic disease
artery carotid artery from aortic arch • Acute obstruction due to emboli from the heart
Brachial artery High bifurcation of brachial artery • Aneurysms
• Fibrosis of the subclavian and axillary arteries due to
Radial artery High origin from axillary artery
radiotherapy
Ulnar artery High origin from axillary artery • Shoulder and arm dislocation
• Trauma or stab wounds
• Damage caused by arterial access and invasive blood
TABLE 10.2 Major Collateral Pathways of pressure lines
the Upper Arm • Thoracic outlet syndrome
• Raynaud’s phenomenon
Diseased Normal Distal Possible • CREST syndrome
Segment Artery Pathways • Reflex sympathetic dystrophy
Proximal Distal subclavian Vertebral artery, • Vibration white-­finger disease
subclavian artery internal thoracic • Takayasu’s arteritis
artery artery, and thyro- • Giant cell arteritis
cervical trunk
Distal Distal axillary Collateral flow to
indication of SA stenosis or occlusion, associated with
subclavian artery the circumflex
or proximal humeral arteries
reverse flow in the ipsilateral vertebral artery (subcla-
axillary artery vian steal). Disease of distal arteries including digital
Brachial artery Distal brachial Deep brachial
arteries of the fingers can occur in patients with diabetes
artery or prox- artery to the and chronic kidney disease.
imal radial and recurrent radial In asymptomatic disease, patients are normally
ulnar arteries and ulnar arteries treated using best medical therapy to reduce cardio-
Radial and ulnar Distal radial and Interosseous artery vascular risk. Asymptomatic patients with subclavian
arteries ulnar arteries and branches stenosis can be considered for interventional treat-
of the recurrent ment if they have an ipsilateral arteriovenous fistula
radial and ulnar for dialysis or an ipsilateral internal mammary artery
arteries graft to the coronary arteries. Symptomatic patients
can be treated by angioplasty plus or minus stent-
ing, provided that the lesion is suitable for dilation.
Symptoms and Treatment of Upper-­ Arterial bypass surgery is rarely performed in the
upper extremities. Acute obstructions can produce
Limb Arterial Disease marked distal ischemia, and the forearm and hand
The main causes of upper-­limb disorders are shown in may be cold and painful. In many cases of acute isch-
Box 10.1. Many patients with chronic upper-­limb arte- emia, the condition of the arm and hand improves
rial disease experience few symptoms because of the with appropriate anticoagulation. However, embo-
development of good collateral circulation in the arm. lectomy, thrombolysis, or bypass surgery may be per-
The presence of disease may only become apparent when formed if there is persistent distal ischemia. Trauma,
cervical or supraclavicular bruits are detected, a differ- due to injury or stab wounds to the arm or shoulder,
ence between arm systolic blood pressure is recorded, can result in arterial damage, requiring local repair
or if there is a diminished brachial or radial artery pulse or bypass surgery. SA or axillary artery aneurysms
(Clark et al. 2012). However, some patients complain of can be bypassed with grafts, although in some cases
aching and heaviness in the arm following a period of endovascular repair can be performed by deploying a
use or exercise. Vertebrobasilar symptoms can also be an covered stent across the aneurysm to exclude flow in
182 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

the aneurysm sac. Occasionally, patients with vascu-

lar malformations will be encountered. These can be
venous or arteriovenous malformations, ranging in
size and distribution, and can affect the fingers, hand,
or arm or multiple sites.

Practical Considerations and

Patient Positioning for Duplex
Assessment of Upper-­Extremity
Arterial Disease

Objectives of an Upper-­Limb
Arterial Scan
• Locate, identify, and grade the severity of atheroscle- Fig. 10.3 Scanning position for imaging the distal axillary, bra-
rotic disease chial, radial, and ulnar arteries. To image the mid-­axillary artery
from the axilla (blue arrow), the arm can be abducted (direction
• Identify the level of acute occlusions due to embolus
of curved black arrow).
or thrombus and assess the impairment to distal cir-
culation
• Identify dilations and aneurysms, including false
maneuvers. The scanner should be configured for a
aneurysms caused by arterial cannulation
• Assess for arterial thoracic outlet syndrome
peripheral arterial examination, and in the absence of
• Half an hour should be sufficient for most upper-limb a specific upper-­limb preset, a lower-­limb arterial preset
examinations. would be an appropriate alternative. The color scale is
set for detecting medium-­to high-­velocity pulsatile flow
in the SA and axillary artery, typically between 20 and
There is no special preparation required prior to the 30 cm/s. For the radial and ulnar arteries, the scale often
scan, although the patient will have to expose the shoul- needs to be lowered to 15 to 20 cm/s.
der and upper arm for scanning of the distal SA and
axillary arteries. The examination room should be at a
comfortable ambient temperature (>20°C) to prevent
Scanning Techniques
vasoconstriction of the distal arteries. It is possible to A mid-­frequency linear array transducer is the most suit-
scan the arm vessels with the patient in a sitting position able probe for scanning the SA and axillary arteries. A high-­
or lying supine. When scanning the patient in a supine frequency linear array transducer produces the best images
position, the head can be supported on a pillow for com- of the brachial, radial, and ulnar arteries, particularly as the
fort and the SA and proximal axillary artery scanned radial and ulnar arteries are very superficial at the wrist. A
with the operator sitting at the side of the patient or at hockey-­stick probe can be useful at this level. Imaging of the
the end of the examination couch behind the patient, digital arteries is easier with a hockey-­stick probe. In addi-
similar to a carotid scan. To image the distal axillary and tion, a mid-­frequency curvilinear array transducer can be
brachial arteries, the patient should be examined from useful for imaging the proximal SA at the level of the supra-
the side of the examination table and the arm should clavicular fossa, as it fits more easily into the contour of this
be abducted, externally rotated, and resting on an arm region. The transducer positions for imaging the upper-­
board or a suitable rest (see Fig. 10.3). The distal bra- extremity arteries are shown in Fig. 10.4. A color flow mon-
chial, radial, and ulnar arteries are imaged with the hand tage of the upper-­extremity arteries is shown in Fig. 10.5.
in a palm-­up position (supination), resting on a support.
Scanning the patient in the sitting position is particularly Subclavian and Axillary Arteries
useful for thoracic outlet examinations, as this enables The SA is initially located in a transverse plane in the
full freedom of arm movement during provocation supraclavicular fossa, where it will lie superior to the
 CHAPTER 10 Duplex Assessment of Upper-­Limb Arterial Disease 183

subclavian vein. The transducer is turned to image the left SA origin is normally difficult to image with a stan-
artery in longitudinal section and followed proximally. dard linear array transducer, as the vessel arises from the
On the right side, it can often be possible to image and aortic arch. It can sometimes be tracked toward its ori-
investigate flow in the distal brachiocephalic artery. The gin with a low-­frequency phased array or mid-­frequency
curvilinear transducer. This type of transducer can also
be useful for imaging the proximal and mid-­section of
Supraclavicular fossa
the brachiocephalic artery, as it has a small footprint that
allows access to the limited imaging window. Sometimes
Clavicle
the origin of the right SA can be difficult to image, espe-
cially if the patient has a large or short neck or if there
Infraclavicular fossa is significant respiratory movement. Extra gel may be
needed to fill the depression of the supraclavicular fossa
Axillary artery Subclavian
to enable good contact with a linear array transducer.
artery
The SA should then be followed distally in longitudinal
section, where it will disappear underneath the clavicle.
There will be a large acoustic shadow below the clavicle
Brachial artery
(see Fig. 10.5). A mirroring artifact of the SA is often seen
due to the chest wall beneath the artery (see Fig. 4.23).
The SA reappears from underneath the clavicle
and is followed distally, where it becomes the axillary
artery. Two positions may be used to image the length
of the axillary artery. The first is the anterior approach,
in which the axillary artery will be seen to run deep
beneath the shoulder muscles. A low-­frequency curvi-
Radial artery Ulnar artery linear transducer can sometimes be useful for following
the distal axillary artery from this position as the axil-
lary artery can lie quite deep in the image at this point.
The second approach images the axillary artery from the
axilla (armpit), with the arm abducted, where it can be
followed distally to the brachial artery (Fig. 10.3).
It is worth noting that the proximal segment of the
internal thoracic artery, a branch of the SA, can often
be imaged from the supraclavicular fossa. This artery
is frequently used in coronary bypass surgery and is
surgically grafted to the heart. It divides at a 90° angle
from the inferior aspect of the SA to run down the chest
wall. Beyond its origin it runs behind the upper ribs and
Fig. 10.4 Transducer positions for scanning the upper-­ is only visible in the spaces between them. It is possi-
extremity arteries. ble to confirm graft patency by identifying flow in the

C
SA AA BA RA

DB
UA

Fig. 10.5 A color flow montage of the left upper-­extremity arteries demonstrating the subclavian artery (SA),
axillary artery (AA), brachial artery (BA), deep brachial artery (DB), radial artery (RA), and ulnar artery (UA). A
large acoustic shadow is seen due to the clavicle (C).
184 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

A B
Fig. 10.6 A Doppler waveform recorded from a left thoracic
artery grafted to a coronary artery following heart bypass sur-
gery. The systolic phase is shown by the arrows.

proximal thoracic artery just beyond its origin. The flow

pattern in the artery supplying the heart will exhibit an Fig. 10.7 Doppler recording from the distal radial artery
unusual waveform shape, as most of the flow occurs in demonstrating the effect of temperature on flow. (A) indicates
the diastolic phase of the cardiac cycle (see Fig. 10.6). strong triphasic flow recorded in a very warm room. (B) Shows
a reduction in flow with increased peripheral resistance after
Brachial Artery the hand was cooled, and room temperature reduced.
The brachial artery is followed as a continuation of the
axillary artery along the inner aspect of the arm to the It is often easier to locate the radial and ulnar arter-
elbow, where it curves around to the cubital fossa and ies at the wrist and then to follow them back to the
lies in a superficial position. The distal brachial artery is elbow.
scanned across the elbow to the point where it divides in
the upper forearm into the radial and ulnar arteries. The Palmar Arch and Digital Arteries
level of the brachial artery bifurcation does vary and can Duplex scanning can be used to image the palmar arch and
be high in the arm and is easier to locate in transverse digital vessels, although continuous-­wave (CW) Doppler
plane. can be considerably quicker and easier to use for the detec-
tion of arterial signals, especially in the digital arteries. It
Radial and Ulnar Arteries is recommended to use a CW probe having a minimum
frequency of at least 8 MHz. However, high-­frequency
Caution hockey-­stick transducers can provide detailed B-­mode and
Cold examination rooms or cold ultrasound gel applied color images of the digital arteries and are easier to manip-
to the hand can cause significant peripheral vasocon- ulate than standard transducers for this assessment. With
striction leading to high-­resistance flow signals in the the hand palm up, apply the probe at an approximate 45°
radial ulnar and digital vessels that may not be de- angle to each side of the fingers to locate the digital arteries.
tected with a default upper-­limb scanner setting (see The radial artery is sometimes harvested to be used
Fig 10.7). The color scale may have to be reduced to as a graft for coronary artery bypass surgery. It can also
8 to 10 cm/s. There can also be a cyclical appearance
be used for maxillofacial reconstructive surgery. To
from low to high resistance flow over a period of about
ensure that the ulnar artery will maintain perfusion to
20 seconds (Fig. 10.8).
the hand, it is possible to listen to arterial flow signals in the
hand with CW Doppler and then manually compress
the radial artery. If the arterial signal from the hand is
The bifurcation of the brachial artery into the radial severely diminished or disappears, removal of the radial
and ulnar arteries is easier to locate in a transverse plane. artery could result in hand ischemia. Alternatively, an
The two arteries are then followed distally to the wrist in Allen’s test can be performed. The hand is clenched tight
a longitudinal plane. In its proximal segment, the ulnar and then the radial and ulnar arteries are simultaneously
artery runs in deep below the muscles and flexor tendons compressed at the wrist with finger and thumb pres-
before becoming more superficial in the mid-­forearm. sure to occlude them. The hand is then opened while
 CHAPTER 10 Duplex Assessment of Upper-­Limb Arterial Disease 185

maintaining pressure on each artery. At this point, pres-

sure on the radial artery is released. Rapid “pinking” or
reperfusion of the hand confirms flow continuity into
the hand. However, if the hand remains blanched for
more than 10 to 20 seconds, this indicates limited or
poor perfusion from the radial artery. The test is then
repeated with pressure being released from the ulnar
artery to assess its contribution. Fig. 10.8 A cyclical change in the appearance of the blood flow
patterns in the radial and ulnar arteries can be observed, relat-
ing to factors such as the control of body temperature.
Problems
• The proximity of major veins and arteries in the region
the waveform can become multiphasic. The average
of supraclavicular fossa can present a confusing dis-
peak systolic velocity in the SA has been reported in the
play, and venous signals may appear pulsatile due to
the proximity of the right side of the heart. region of 70 to 120 cm/s, but this will vary with age
• There may be mirroring artifact of the subclavian due (Talbot 2012). It is often assumed that the radial artery
to the chest wall (see Fig. 4.23). is the dominant vessel in the forearm because it is easier
• Imaging of the axillary artery can be difficult where the to palpate at the wrist, but in some cases there is higher
artery runs deep under the shoulder muscles. Scan- flow in the ulnar artery.
ning from the axilla or selecting a lower-­frequency
probe may help. Abnormal Appearance
• With B-­mode imaging, it can be initially difficult to dif- Any atheroma is normally visible in the arm arteries
ferentiate the brachial artery from adjacent brachial due to their superficial position except for the proximal
and basilic veins in the upper arm. Transverse color
SA. Sometimes areas of micro-­calcification can be seen
flow imaging can help identify the artery and the
in the mid to distal radial and ulnar arteries, but the
veins should be compressible with moderate trans-
ducer pressure. arteries usually remain widely patent. In the absence of
any specific criteria for grading upper-­limb disease, we
would advocate the same criteria as for grading lower-­
Ultrasound Appearance limb disease. Therefore, a doubling of the peak systolic
velocity across a stenosis compared with the proximal
Normal Appearance normal adjacent segment indicates a >50% diameter
The normal appearance of upper-­extremity arteries is the reduction (Fig. 10.9). However, many upper-­limb lesions
same as that described for the duplex scanning of lower-­ are located at the origin to the SA, making proximal
limb arteries (see Ch. 9). The spectral Doppler waveform measurements from the aortic arch or brachiocephalic
is normally triphasic at rest but becomes hyperemic artery unreliable or impossible due to vessel depth, size,
with high diastolic flow following exercise. Changes in and geometry. In this situation the diagnosis is usually
external temperature can have marked effects on the made by indirect signs, such as high-­velocity jets, turbu-
observed flow patterns in the distal arteries (Fig. 10.7). lence, or poststenotic damping (Figs. 10.10 and 10.11).
There is a cyclical effect on the appearance of the flow Mousa et al. (2017) found that a peak systolic velocity
patterns in the distal arteries toward the wrist and hand of 240 cm/s has good sensitivity for detecting a >70%
related to factors such as body temperature control. This SA stenosis. In addition, the ipsilateral vertebral artery
cyclical effect can cause the waveform shape to change should be examined for evidence of subclavian steal (see
from high-­resistance flow to hyperemic flow within the Ch. 8). It can also be difficult to visibly identify plaques
space of a minute (Fig. 10.8). Peripheral vasodilation at the origin to the SA. Occlusions of the proximal SA
will cause a reduction in peripheral resistance and an can be difficult to differentiate from severe stenoses, par-
increase in flow. In this situation, the waveform in the ticularly on the left side and any uncertainty should be
radial and ulnar arteries can become hyperemic and highlighted in the report. If there is suspicion of exten-
reverse flow may be absent. Vasoconstriction increases sive arch disease, CTA or MRA will provide more detail.
peripheral resistance, causing a reduction in flow, and Dissection of the radial, brachial, or axillary arteries can
186 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

A B

C D D
E
F

Fig. 10.9 A high-­grade stenosis of the proximal brachial artery. (A) Color flow imaging demonstrates the
severe stenosis. The proximal deep brachial artery is seen in this image. (B) B-­mode imaging demonstrates
mainly low echogenicity atheroma (arrows). (C) A diagram showing the transducer positions of recorded Dop-
pler waveforms, (D) proximal to the stenosis, (E) across the stenosis and (F) distal to the stenosis. The corres­
ponding Doppler waveforms are shown in parts D, E, and F. Note the damped monophasic flow seen in F.

A B

Fig. 10.10 A severe stenosis of the left subclavian artery. (A) MRI scan demonstrating the stenosis (arrow).
(B) Color flow image demonstrating the stenosis (arrow). (C) Doppler recordings across the stenosis indicate
an abnormally high velocity of 452 cm/s. (D) There is marked damping of the brachial artery waveform distally,
indicating the hemodynamic significance of the stenosis.
 CHAPTER 10 Duplex Assessment of Upper-­Limb Arterial Disease 187

A B

Fig. 10.11 (A) A stenosis of the proximal left subclavian artery is demonstrated by marked color flow dis-
turbance and aliasing. High peak systolic velocity (282 cm/s) is recorded in the region of the stenosis. (B)
Doppler waveforms from the ipsilateral vertebral artery demonstrate a systolic dip (arrow) due to the proximal
subclavian artery stenosis (see Ch. 8). This figure represents the real-­life difficulty when attempting to image
and grade subclavian artery disease, as this stenosis was difficult to image in B-­mode. The presence of a color
bruit and mirroring artifact due to the chest wall makes positioning of the sample volume and angle correction
difficult. A low-­frequency curvilinear or phased array transducer may have helped.

occur due to trauma of the vessel wall following catheter collapses with transducer pressure. A low color flow
access. It may be possible to see flaps, dual lumens, or scale is required to demonstrate flow in these lesions.
acute obstruction.
Acute occlusions of upper-­extremity arteries are fre-
quently caused by embolization from the heart and occur
Thoracic Outlet Syndrome
most commonly in the brachial, radial, and ulnar arter- The vascular laboratory is frequently asked to assess
ies. The arterial lumen may appear relatively clear, but patients with suspected TOS. The thoracic outlet is
there will be an absence of flow in the vessel, as demon- defined by an area through which the subclavian vein,
strated by color flow imaging (Fig. 10.12). Requests can SA, and brachial plexus all emerge as a neurovascular
be made for repeat scanning of acute occlusions follow- bundle. Anatomically, the outlet is defined superiorly
ing anticoagulation therapy, as there can be no, partial, and inferiorly by the clavicle and first rib, respectively;
or full recanalization of affected vessels. Some acute this area is called the costoclavicular space. The SA and
occlusions occur as a result of embolization from the SA brachial plexus leave the chest and pass between the
due to damage caused by TOS. anterior and middle scalene muscles over the first rib
The SA and axillary artery are also sites of large-­ and underneath the clavicle (Fig. 10.13). This is a com-
vessel arteritis (see Ch. 8). Lesions are characterized by pact anatomical area, and compression on the nerves or
enlargement of the media layer that has uniform echo- arteries by a number of mechanisms can produce sen-
genicity around the circumference of the vessel. Investi- sory symptoms in both the hand and arm. Compression
gation of the arm arteries for arteritis occurs for patients can occur in three main areas. The first is at the point
with upper-­limb symptoms (for example, poor radial where the SA passes between the scalene muscles and
pulses) and as part of protocols for investigation of giant can be caused by muscle hypertrophy or fibrous bands
cell arteritis. or may be due to the presence of an additional acces-
Large arteriovenous malformations will be imme- sory rib originating from the seventh thoracic vertebra,
diately obvious with color flow imaging as a region of termed a cervical rib (Fig. 10.14). Accessory ribs occur
high vascularity. Spectral Doppler will demonstrate in less than 1% of the population (Makhoul & Machleder
low-­resistance, high-­volume flow waveforms within 1992). The second area of compression occurs as the
the malformation and often the artery proximal to the artery runs between the first rib and clavicle. Fibrous
malformation. In venous malformations, multiple dark bands or fibrosis due to injuries in this region, such as
spaces may be seen in the mass that is often soft and fractures of the clavicle, can also cause compression.
188 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

UA

RA

Fig. 10.12 An embolus from the heart has acutely obstructed the distal brachial artery and bifurcation. (A)
B-­mode imaging shows the embolus (straight arrow) in the artery. The origin of the ulnar artery (UA) is vis-
ible (curved arrow). (B) A transverse image following initial anticoagulation shows an eccentric area of flow
(arrow). (C) This longitudinal image shows an improving situation a day later, with some areas of recanaliza-
tion. The radial artery (RA) is patent.

The third, less common area of compression occurs in compression of the brachial plexus alone (this accounts
the subcoracoid region, where the axillary artery runs for approximately 90%–95% of cases). Neurogenic TOS
under the pectoralis minor muscle and close to the cora- often produces abnormal nerve conduction recordings
coid process of the scapula. and can be associated with muscle weakness and wast-
Typically, the vessels and nerves are compressed ing in the lower arm or hand.
when the arm is placed in specific positions. The symp- Arterial and venous TOS is less common and
toms include intermittent pain, numbness, and tingling, accounts for less than 10% of cases, although there is
“pins and needles” in the hand, hand weakness, sensory sometimes a combination of neurogenic and vascu-
changes, and other neurological disorders on the ipsi- lar compression. Aneurysmal dilations of the SA are
lateral side. It can be difficult to distinguish these from sometimes seen just distal to the point of compression
other causes such as disc disorders or complex regional due to poststenotic dilation. These aneurysms can be
pain syndrome. TOS can be purely neurogenic, due to the source of distal emboli in the fingers, which can
 CHAPTER 10 Duplex Assessment of Upper-­Limb Arterial Disease 189

Anterior scalene Maneuvers for Assessing TOS

muscle Middle scalene CW Doppler recording of the radial artery signal, per-
muscle formed with the arm in a range of positions, can be a
Sternocleido- useful prelude to the duplex examination. There are a
mastoid Clavicle
muscle
range of provocation maneuvers that can be used (Fig.
10.15). Unfortunately, testing can be associated with
false-­positive and false-­negative responses, and find-
ings should be interpreted with caution. Like popliteal
entrapment syndrome, compression of the SA has been
Brachial plexus demonstrated in asymptomatic healthy volunteers. The
Subclavian artery maneuvers may need to be repeated a number of times to
obtain consistent readings. It should be noted that there
Thoracic outlet
appears to be considerable variability in the descriptions
Sternum 1st rib
of these tests for thoracic TOS in medical literature.
Fig. 10.13 The anatomy of the thoracic outlet. Adson’s Test
The patient is seated, and the arm abducted 30° at the
Additional cervical rib 7th cervical vertebra shoulder, and the arm then maximally extended or
pulled down. Then the patient is asked to extend their
Clavicle 1st rib
1st thoracic neck and rotate their head toward the side being tested
vertebra
and instructed to take a deep breath and hold it. The
radial artery can be palpated during the test to see if it
disappears during the maneuver.

Roos Test
In this test, the patient raises their arms to 90° of abduc-
tion in the frontal plane of the body with the arms fully
Sternum
externally rotated so the palms of the hands are pointing
forward and the elbows at 90° of flexion (surrender posi-
Subclavian artery
tion). The patient then opens and closes their hands for
2 to 3 minutes.

Hyperabduction Test
The patient should be sitting comfortably, and the arm
should then be slowly extended outward (abducted).
Fig. 10.14 The presence of a cervical rib originating from the
seventh thoracic vertebra can cause compression of the bra-
With the arm fully abducted, the forearm is rotated so
chial nerve plexus and subclavian artery. that the palm faces upward and the elbow downward
(external rotation). The arm should be raised and low-
be the initial presentation of a patient with TOS. There ered in this position and the patient’s head turned away
is still considerable debate about the assessment and from the side under investigation. This test can indicate
treatment of TOS, which often involves surgical resec- compression between the clavicle and first rib or cora-
tion of a cervical rib and sometimes the first rib, with coid region.
the division of any fibrous bands to relieve the com-
pression (Illig et al. 2016). Although the majority of Costoclavicular Maneuver
patients who have undergone surgery show improve- The patient is asked to push the chest outward while
ment in symptoms, a few show no signs of improve- forcing the shoulders backward with deep inhalation,
ment and may return to the vascular laboratory for the so-­called military position, as this may reveal arte-
further assessment. rial compression between the clavicle and first rib.
190 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

A B C

Fig. 10.15 Provocation maneuvers used for the assessment of thoracic outlet syndrome. (A) Adson’s test.
(B) Roos test. (C) Hyperabduction test.

Deep Inspiration Maneuver position if the arm is abducted due to movement of the
During deep inspiration the patient is asked to extend shoulder. Any changes in the flow pattern or areas of sig-
the neck and rotate the head to the affected side and then nificant velocity increase in the SA during provocation
to the other side while the pulse is checked at the wrist. tests should be recorded. Typically, most high-­velocity
A positive test indicates possible compression between jets are recorded in the region of the clavicle (Fig. 10.16).
the scalene muscles or the presence of a cervical rib. There are no clearly defined criteria as to the point at
Finally, the patient should also be asked to place the which TOS is indicated, but a doubling of the peak sys-
arm in any position that provokes symptoms, such as tolic velocity at one location is indicative of a hemody-
raising it above the head. In some cases, this will lead to namic effect. Patients with severe vascular symptoms
a positive result even though the maneuvers above may show complete occlusion of the SA during provocation
have been negative. Any change to, or loss of, the Doppler maneuvers, posing less of a diagnostic dilemma. Many
signal during these maneuvers suggests compression of clinicians request examination of both arms, as both
the SA. The patient should also be asked to indicate any sides could be positive but only one symptomatic, and
symptoms that occur during arm maneuvers, as a nor- this may suggest that treatment of the symptomatic side
mal Doppler signal in the presence of symptoms may may be less beneficial.
indicate a nonvascular cause for the complaint.

Duplex Assessment of TOS Aneurysms

It is generally easier to image the arteries with the Aneurysms involving the upper extremities are rare and
patient in a sitting position so that provocation tests are most frequently seen in the SA, associated with TOS
can be performed. The SA is initially imaged from the (Fig. 10.17). False aneurysms or pseudoaneurysms are
supraclavicular and infraclavicular positions. The flow most commonly seen in the radial, brachial, or axillary
velocities are recorded and any abnormalities, such as artery following arterial puncture for catheter access. It
tortuosity or aneurysmal dilations, noted. The SA can is important to remember that some false aneurysms can
then be imaged using any of the provocation maneuvers originate from the posterior wall of the artery if the cathe-
that were found to reduce or obliterate the radial artery ter has punctured both walls. Localized swelling following
signal with CW. It is easiest to image the SA adjacent arterial puncture can be due to hematoma, and ultrasound
to the clavicle in the infraclavicular area (see Fig. 16.3) can confirm or exclude a false aneurysm (Fig. 10.18).
with the patient’s arm in resting position. Then ask the Some patients present to the clinic with visible pulsatile
patient to slowly undertake the appropriate provocation swelling in the supraclavicular fossa, which is usually on
maneuver while observing the color flow display. It will the right side of the neck. This is invariably due to tortuos-
be necessary to make slight adjustments to the probe ity of the distal brachiocephalic artery, proximal common
 CHAPTER 10 Duplex Assessment of Upper-­Limb Arterial Disease 191

A B

Fig. 10.16 (A) A color flow image of the subclavian artery as it passes underneath the clavicle (C) with the
arm at rest and the artery widely patent. (B) Following arm abduction, there is marked compression of the
subclavian artery associated with color aliasing (arrow), indicating thoracic outlet syndrome. Note the large
acoustic shadow below the clavicle.

Fig. 10.17 A power Doppler image of a distal subclavian and proximal axillary artery aneurysm that has devel-
oped in a patient with thoracic outlet syndrome.

carotid artery, and proximal SA (see Ch. 8). Occasionally, Raynaud’s phenomenon can be a primary disorder
pulsatile swellings are seen in the area of the radial or related to vasospasm in the fingers or a rarer and more
ulnar artery at the wrist, and this can be due to a ganglion serious secondary disorder associated with connective
lying adjacent to the artery and distorting its path. tissue diseases such as scleroderma or CREST syn-
drome (Calcinosis, Raynaud’s phenomenon, Esophageal
Other Disorders of the Upper-­ dysfunction, Sclerodactyly, Telangiectasia). Primary
Raynaud’s phenomenon produces symptoms of digital
Extremity Circulation ischemia in response to changes in ambient temperature
Some hand and arm symptoms are due to microvascular and emotional state. This is observed as color changes
or neurological disorders. Duplex scanning can exclude of the fingers, causing blanching, or bluish discolor-
large-­vessel disease, but patients suffering from these ation due to cold. The blanching is followed by a period
types of abnormalities are best evaluated in specialist of rubor (redness) caused by hyperemia as the fingers
microvascular units. warm. These signs may be mistaken for the presence
192 Chapter 10 Duplex Assessment of Upper-­Limb Arterial Disease

causes more persistent symptoms and in extreme cases

A can result in amputation of one or more fingers.
Vibration white-­finger disease is a disorder caused by
the use of drills and other vibrating machinery over a long
period of time, leading to damage to the nerves and micro-
vascular circulation in the fingers and hand. It can result in
blanching of some or all of the fingers, loss of sensation, and
loss of dexterity. Again, Doppler signals may be normal to
wrist level. However, Doppler recordings may demonstrate
B high-­resistance flow patterns in the digital arteries due to
the increased resistance to flow caused by the damaged
arterioles and capillary beds. If the damage is severe, no
flow may be detected with Doppler interrogation.
Reflex sympathetic dystrophy (RSD) is a poorly
understood condition that usually occurs after local
trauma, sometimes minor, to the hand or arm and results
in severe pain, sensitivity, and restricted movement of
the affected area. Patients often report pain that is out
of proportion to the severity of the injury, which might
be a simple sprain or bruise. The condition can persist
for many months, and intensive treatment is sometimes
required to restore full use to the limb. This condition
Fig. 10.18 (A) A localized area of arm swelling associated with can affect young adults and children. The hand or arm
tenderness is seen following radial artery catheterization that
may feel cold to the touch and appear discolored or cya-
could indicate a false aneurysm. (B) A transverse duplex image
demonstrated a large area of hematoma overlying the artery nosed. However, Doppler recordings usually demon-
coded red. No false aneurysm was identified, and the hema- strate pulsatile arterial signals in the brachial, radial, and
toma is reasonably echogenic with no anechoic spaces. Note ulnar arteries. RSD can also affect the lower extremities.
the difficulty of imaging in the arm and in areas of localized
swelling with a flat linear probe, as it is easy to lose contact
with the skin (region with arrow) due to the acute curvature of Reporting
the arm or swelling.
The simplest form of reporting upper-­extremity investi-
gations is with the use of diagrams and images, similar
of atherosclerotic occlusive disease, but pencil Doppler to the method used for lower-­limb investigation (see
recordings will detect pulsatile flow signals in the radial Fig. 9.24) This can be associated with a brief report. In
and ulnar arteries, and the brachial systolic pressure the case of TOS, a written report may suffice with appro-
should be equal in both arms. Secondary Raynaud’s priate images.