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INTRODUCTION

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Loss of arm and hand function arguably carries higher morbidity than that of the leg, as there seems to be an unspoken stigma associated with arm or hand loss. Upper extremity function is critical to human interaction within the environment. Hand strength, sensation, and other complex functions protect and provide for human survival and socialization.

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Vascular disorders of the upper extremities result in symptoms ranging in severity from nuisance to limb-threatening. Patients with arm-related vascular pathology are encountered by physicians with lesser frequency than lower extremity vascular disease, making diagnosis and treatment unfamiliar to many clinicians who are otherwise skilled in the care of vascular disease. It is paramount that the clinician be able to recognize many of the upper extremity arterial disorders to prevent both overly aggressive treatment, as well as treatment omissions that could lead to tissue loss. This chapter serves to provide an overview of the diagnosis and treatment of frequently encountered vascular disease patterns of the arm.

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The arm's arterial supply consists of the brachiocephalic vessels of the aortic arch, as well as the run-off arterial anatomy of the upper extremities. The disease processes are broken down into three major groups: arterial occlusive/embolic disease, arterial inflammatory disease, and aneurysmal disease of the branch vessels and upper extremities.

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In approximately 92% of the population, the aortic anatomy includes, from right to left, the innominate artery, the right common carotid artery, (succeeded across the arch by the origin of the left common carotid artery), and the left subclavian artery. Depending on congenital formation and obliteration of primordial arches allowing for tortuous changes. Over time, the origins of the great vessels can vary in their initiation across the curve of the aortic arch. In general, the more proximal the take-off of the great vessels from the ascending aortic arch, the more difficult catheter-based access becomes when endovascular surgery is performed for subclavian and carotid arterial disease (Figure 28-1).1,2

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FIGURE 28-1.

Great vessels arising far right within the aortic arch present challenges in the endovascular treatment of both occlusive and aneurysmal disease of Axillo-subclavian arterial segments.

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In 2% to 6% of patients, the left common carotid artery takes its origin from the innominate artery. This arrangement termed bovine arch, can increase the complexity of intervention for innominate arterial disease, as the majority of cerebral inflow is dependent upon the innominate artery. In general, the innominate artery is the largest branch arising from the arch of the aorta. Its origin occurs at the upper border of the second right costal cartilage and because of the angulation of the aortic arch, it is found anterior to the left carotid in the anterior–posterior plane. The innominate artery typically gives off no branches but in 1% of patients a thyroidea IMA takes ...

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