URR Upper Extrem Arterial Abnormalities

Question 1

what is thoracic outlet syndrome (TOS)?

Answer 1

-muscular band, cervical rib or fibrous band crosses the brachial plexus nerves in an abnorm location that causes compression w/ certain arm maneuvers
-most patients asymptomatic
-may see dull aching pain, radiating from point of compression
-may see paresthesia/numbness, pain, increased symptoms with certain arm/neck positions or exercise
-may see extrem swelling w/ venous TOS
-symptoms usually intermittent and vary w/ patient position

Question 2

what is neurogenic TOS

Answer 2

-most common type (>90%)
-compression of the brachial plexus from cervical ribs, anterior scalene muscles and ligaments
-causes paresthesia, numbness, pain
-US eval will not identify the cause of the symptoms if only the nervous system is affected

Question 3

what is arterial TOS?

Answer 3

-least common (1%)
-subclavian artery compression from the head of the humerus

Question 4

what is venous TOS?

Answer 4

-subclavian vein compressed against the first rib and scalenus anticus muscle w/ abduction of the arm
-also called paget-schroetter syndrome or effort thrombosis

Question 5

how to do exam for TOS?

Answer 5

-eval for atherosclerosis
-establish normal flow patterns and then eval changes with change in position
-patient seated with palms up
-sweep speed reduced
-waveforms should be similar or larger than the resting postion waveforms
-reduction in amplitude or “flatline” indicates a positive exam
-PPG or PVR are preferred over Doppler
-PPG of 2nd digit/index at rest and w/ maneuvers
-PVR with a brachial cuff at rest and with maneuvers
-doppler arterial:
-eval radial A at wrist
-obtain doppler
-perform TOS
-repeat doppler
-doppler venous
-eval dist subclav vein
-establish baseline flow
-perform TOS maneuvers
-repeat doppler

Question 6

what are the TOS maneuvers?

Answer 6

inspiration/expiration used w/ change of position in some maneuvers
-resting neutral position, hand on lap
-arm at 90 degree angle to body
-arm at 180 degree angle to body
-adsons maneuver
-exaggerated military posture (costoclavicular)
-neutral position with head left/head right
-any position that the patient experiences symptoms

Question 7

what is adsons maneuver

Answer 7

-palpate the radial pulse on affected side w/ the elbow fully extended. Have the patient rotate their head to the side being tested and extend the neck
-then abduct, extend, and laterally rotate the shoulder
-from this position, have the patient take a deep breath and hold
-assess the pulse response
-a positive test is a decrease in pulse vigor from the starting position to the final one

Question 8

what are abnorm findings for TOS?

Answer 8

-PPG/PVR significantly reduced amplitude or absent signal w/ patient maneuvers
-arterial doppler significantly reduced or absent signal with patient maneuvers
-venous doppler venous signal will become continuous or disappear
-when a change in a waveform is noted, ask the patient if they are experiencing symptoms
-abnormal exam results + patient symptoms = positive exam for TOS

Question 9

what is hypothenar hammer syndrome

Answer 9

-ulnar A is commonly affected because it crosses over the hook of hamate bone
-can be caused by repetitive compression or blunt trauma
-associated with raynaud syndrome
-pain in palm of hand and with cold sensation
-most commonly causes ischemia of fourth and fifth digits
-positive tinel sign = distal paresthesia induced by compression of the affected portion of the entrapped ulnar nerve
-positive allen test
-occlusion of the distal ulnar A
-may also see irregular contour or aneurysm of the ulnar A

Question 10

what does the double aortic arch compress

Answer 10

anterior aspect of the trachea and posterior aspect of the esophagus

Question 11

what does the pulmonary sling compress

Answer 11

anterior aspect of trachea and posterior aspect of esophagus

Question 12

what does the left aortic arch with aberrant right subclavian A compress

Answer 12

esophagus

Question 13

what does the right aortic arch with aberrant lt subclavian compress

Answer 13

esophagus

Question 14

what is innominate A compression syndrome

Answer 14

tracheal compression by the innominate occurring in children, norm growth usually resolves the tracheal compression

Question 15

what is takayasu arteritis

Answer 15

-presents as hypertrophic areas of inflamed tissue usually found in the ao and its branches
-associated with supravalvular stenosis and aortic coarctation
-commonly affects the subclavian and carotids
-can also affect the renal arteries
-most commonly seen in young females

Question 16

what is raynaud syndrome

Answer 16

-vasospatic disorder that presents as response to cold or emotional stimuli
-can be associated with lu[us scleroderma, rheumatoid arthritis
-70% occurs in females
-vasoconstriction of digital arteris occrs in response to stimuli
-cold and emotional stimuli are triggers
-stimuli causes a series of color changes in the affected area; after the application of stimuli the area will turn white due toischemia caused by vasoconstriction, then blue due to cyanosis in the tissues and finally red with vasodilation causing localized “flushing” phenomenon

Question 17

what is primary raynauds?

Answer 17

-called raynaud syndrome / disease
-occurs in a NORMAL vasc system
-bilat digital arterial spasm- INTERMITTENT
-more common in women
-symptoms only occur when arterial spasm is present and are present more than 2 years

Question 18

raynauds is more common in the what?

Answer 18

hands than feet

Question 19

what is secondary raynauds

Answer 19

-called raynaud phenomenon
-occurs in ABNORMAL obstructed system w/ vasoconstriction causing constant ischemia
-may be unilateral
-pain is usually constant w/ significant arterial obstruction
-in contrast to raynauds disease, phenomenon presents concurrently with CREST sydrome, in which tissue necrosis results from spastic occlusive disease
-CREST syndrome involves symptoms of generalized calcinosis, raynaud phenomenon, esophageal dysfunction, scleroderma, telangeictasia

Question 20

protocol for raynauds?

Answer 20

-r/o arterial stenosis and eval vascular response to stimuli
-pateint sitting
-eval brachial, radial and ulnar w/ doppler and PVR to rule out stenosis
-obtain brachial pressures
-place cuff around middle phalanx of the digit bring evaled and obtain pressure
-calculate baseline digit/brachial index using highest brachial pressure
-PPG sensor on pad of digit
-PPG testing of digits at rest
-if baseline PPG tracings are NORMAL and symptoms are caused by stimuli cold sensitivity testing should be performed

Question 21

how to do cold sensitvity testing?

Answer 21

-submerge hand in ice H2O up to 1-3 mins
-record subermsion time
-PPG testging immediately after stimuli removed
-PPG testing 5 mins after stimuli removed
-immediately after immersion the amplitude of the waveform will decrease
-abnorm response if the amplitude of the waveform does not return to normal in 5 mins

Question 22

unique characteristic of raynaud

Answer 22

decreased flow w/ double peaked waveform

Question 23

If PPG tracings after rayndauds exam is abnormal, cold sensitivity testing should not be performed, what happens next?

Answer 23

-wrap hands in heating pad for 5 mins
-if tracings return to norm, secondary to raynaud phenomenon is present
-if tracings remain abnorm (like baseline), small vessel occlusive disease

Question 24

what is an uncommon finding in the upper A related to disease?

Answer 24

atherosclerotic disease
-seem to somewhat “resistant” to atheroma formation
-signs and symptoms are the same as PAD in lower extrems
-subclavian steal can be related to atheroma formation in the subclavian A
-norm doppler waveforms have high resistance, triphasic with a spectral windo

Question 25

Collateral formation of subclavian obstruction?

Answer 25

subclavian steal, abdominal and thoracic wall ateries

Question 26

collateral formation of axillary obstruction?

Answer 26

thoracic wall or shoulderco

Question 27

collateral formation after brachial obstruction?

Answer 27

forearm, palmar arches with retrograde filling

Question 28

what is an AV malformation?

Answer 28

-congenital malformation causing connection between the arterial and venous system
-usually an abnormal connection between arterioles and venules w/o a norm capillary bed between them
-usually associated w/ multiple arterio-venous connections and dilated venous collaterals

Question 29

what is an AV fistula?

Answer 29

-acquired condition where arterial and venous flow are mixed
-traumatic or surgically created AV fistula will usually only have a single direct connection between an A and V and NO venous collaterals are present

Question 30

what does flow look like in AV malformation or fistula? what can they lead to ?

Answer 30

-prox arterial flow is low resistive w/ increased diastolic flow
-venous outflow is pulsatile and turbulent
-large or long term AVM or AVF can lead to heart failure
-centrally located AVF will usually lead to CHF, while peripheral AVF will usually cause distal ischemia

Question 31

uncommon finding in the upper extrem related to the A?

Answer 31

aneurysm
-subclavian aneurysms can be associated w/ distal embolization to the fingers
-can be associated w/ chronic mechanical stressing of a vessel; secondary to TOS or hypothenar hammer syndrome

Question 32

hypothenar hammer syndrome commonly causes ischemia to which fingers?

Answer 32

fourth and fifth (fed by ulnar A)