Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • R ev i ew

Bozlar et al.
CT Angiography of Upper Extremity Arterial Systems

Vascular and Interventional Radiology

Review

CT Angiography of the Upper

Extremity Arterial System: Part 2—
FOCUS ON:

Clinical Applications Beyond

Trauma Patients
Ugur Bozlar 1,2 OBJECTIVE. CT angiography using modern MDCT scanners has evolved into a
Torel Ogur 1 highly accurate noninvasive diagnostic tool for the evaluation of patients with pathologic
Minhaj S. Khaja1 abnormalities of the upper extremity arterial system.
Jaime All1 CONCLUSION. Here we focus on the use of this modality in patients with nontraumatic
Patrick T. Norton1 vascular pathologic abnormalities.
Klaus D. Hagspiel1
American Journal of Roentgenology 2013.201:753-763.

Bozlar U, Ogur T, Khaja M, et al.
Keywords: artery, atherosclerotic disease, CT
angiography, extrinsic compression syndrome,
thromboembolic disease, upper extremity, vasculitis
DOI:10.2214/AJR.13.11208
Received May 9, 2013; accepted May 10, 2013.
1
Department of Radiology and Medical Imaging,
University of Virginia Health System, PO Box 800170,
1215 Lee St, Charlottesville, VA 22908. Address
correspondence to K. D. Hagspiel (kdh2n@virginia.edu).
2
Department of Radiology, Gulhane Military Medical
Academy, Ankara, Turkey.
AJR 2013; 201:753–763
0361–803X/13/2014–753
© American Roentgen Ray Society
Atherosclerotic Disease
Atherosclerotic disease affects the upper
extremities disproportionately less than the
lower extremities. However, proximal in-
volvement of the upper extremities is not in-
frequent. Risk factors are no different than
those for other sites of atherosclerotic in-
volvement and include hypertension, dyslip-
idemia, diabetes mellitus, age, and a histo-
ry of smoking [1]. Claudication is the most
common presenting symptom, though most
patients are asymptomatic because of collat-
eral formation. Blood pressure differences
between the upper extremities can frequently
be found in these patients. Symptoms are of-
ten chronic, with more acute symptoms sug-
gesting acute thrombosis or an embolic event
[2]. In the setting of subclavian involvement,
upper extremity symptoms may be masked
or overshadowed by symptoms related to
compromised flow to the ipsilateral verte-
bral artery due to subclavian steal, particu-
larly syncope and presyncope. In patients
with left or right internal mammary bypass
grafts, subclavian artery disease can cause
myocardial ischemia [3]. Atherosclerotic
disease, when identified on imaging, should
prompt inquiry into concomitant sites of in-
volvement processes—namely, cardiovascu-
lar and cerebrovascular involvement [1].
Similar to CT angiography (CTA) for the
lower extremities, upper extremity CTA can
effectively evaluate for stenosis, occlusion,
aneurysm, or embolic events, especially when
they affect vessels proximal to the wrist [4]
(Fig. 1). In our experience, the accuracy for
detecting occlusion is greater than that for ste-
nosis grading, particularly in the small caliber
vessels. This limitation is less of an impedi-
ment in the specific setting of evaluating ath-
erosclerosis, because the involvement is much
more likely to be in proximal larger caliber
vessels. Advances in CT technology are im-
proving the imaging of small vessels of the
hand, with current systems achieving imag-
ing of 0.5-mm isotropic voxels, but the limita-
tion of inconsistently adequate enhancement
of these vessels remains [4].
Thromboembolic Disease
Because of the increased use of antico-
agulation in patients at high risk of arterial
emboli, the incidence of arterial embolism
to the extremities is becoming less common.
Peripheral embolic disease occurs within the
lower extremities twice as often as within the
upper extremities [5]. Although infrequent,
embolic occlusion may lead to major con-
sequences, such as limb loss, organ failure,
and death. Thromboembolism is the leading
cause of upper extremity ischemia [2]. Pa-
tients experiencing peripheral arterial embo-
li have a higher mortality rate than do those
with arterial thrombosis. Most emboli origi-
nate from the heart, most often in the setting
of atrial fibrillation. The extremities are the
most common site of cardiogenic emboli in-
volvement (85%), and, not surprisingly, most
upper extremity emboli are cardiogenic [2].
Cardiogenic emboli to the upper extremities
are often larger than cerebrovascular emboli,
presumably as a result of flow dynamics and
size of the carotid ostia [5]. These larger em-
boli become occlusive within larger caliber

AJR:201, October 2013 753


vessels, and the brachial artery is the most
common site of involvement (85%) [2] (Fig.
2). Paradoxical emboli in the upper extrem-
ity arterial system have been described in
patients with patent foramen ovale or other
right-to-left shunts [6].
There are several sources of emboli that are
unique to the upper extremities, including tho-
racic outlet compression, hypothenar hammer
syndrome, and occluded axillofemoral bypass
grafts. In addition, repetitive positional com-
pression of the axillary artery and its branch-
es, particularly the circumflex humeri artery,
can cause intimal hyperplasia, aneurysm for-
mation, segmental dissection, and branch ves-
sel aneurysms, leading to thrombosis and pe-
ripheral embolization in overhead athletes,
particularly baseball pitchers [7, 8]. Endovas-
cular procedures also constitute a potential
cause of upper extremity thromboembolism.
In this setting, symptoms are typically acute
American Journal of Roentgenology 2013.201:753-763.
and include discoloration, paresthesias, and
petechiae. Later symptoms include ulceration
and gangrene [9].
The imaging appearance of embolic dis-
ease in the upper extremities is similar to
that of other vascular territories. Emboli ap-
pear as filling defects within the larger ar-
teries, typically showing some enhancement
adjacent to the wall of the blood vessel. The
emboli can be either occlusive or nonocclu-
sive. Collaterals are usually absent. In the
smaller arteries, filling defects are not typ-
ically appreciated, and abrupt occlusion is
the dominant finding. In the setting of high
clinical suspicion, CTA may be deferred for
conventional angiography and percutaneous
therapy such as thrombolysis.
Aortic Dissection
Aortic dissection can involve the supra-
aortic branches and can cause symptoms of
cerebral and upper extremity malperfusion.
The imaging appearance of dissections in-
volving the supraaortic branches (Fig. 3)
shows a type A dissection involving the su-
praaortic branches.
Vasculitis
Vasculitis is defined as an inflammatory
process of blood vessels. CTA can diagnose
vasculitis of large and medium arteries non-
invasively. Takayasu arteritis (TA), giant cell
arteritis (GCA), and thromboangiitis obliter-
ans are the most common types of vasculi-
tides that affect the upper extremity vessels.
Acute vasculitis can often be differentiated
from atherosclerotic disease clinically be-
754 AJR:201, October 2013
Bozlar et al.
cause of the presence of constitutional symp-
toms, including fevers, malaise, myalgias, and
arthralgias. Abnormal laboratory values pro-
vide supporting evidence for the diagnosis.
On imaging studies, vasculitis often appears
as long stenoses with gentle tapering, as op-
posed to the focal stenosis and abrupt occlu-
sion of atherosclerosis. Vessel wall thicken-
ing and enhancement are also characteristic
signs. Thus, imaging protocols should include
a delayed phase when vasculitis is suspected.
TA is an inflammatory vasculitis affecting
large and medium elastic arteries [10, 11].
Female patients are much more often affect-
ed than male patients. TA is characterized by
a form of panarteritis, beginning with cellu-
lar infiltration of the adventitia with subse-
quent diffuse or nodular fibrosis of the me-
dia and adventitia [12–14]. Acute progress
of inflammation destroys the media struc-
ture rapidly, causing the formation of aneu-
rysms (Fig. 4). The diagnosis of disease is
often delayed and difficult because of non-
specific symptoms in the early phase. It is in
the chronic phase of the disease when isch-
emic symptoms occur, as a result of arterial
stenosis or occlusion [12].
Digital subtraction angiography (DSA)
has been considered the reference standard
for a definitive diagnosis of TA [12]. Cross-
sectional imaging techniques, such as MR
angiography (MRA) and CTA, show focal or
diffuse tapered stenoses of the involved ves-
sels and mural changes, such as vessel wall
edema and thickening (Fig. 4). Enhancement
of the vessel wall is indicative of active vas-
culitis. Arterial phase CTA images will de-
pict circumferential mural thickening and
inhomogeneous enhancement of the vessel
wall with concentric low-attenuation inner
ring and mural enhancement in the delayed
phase [12, 15]. MDCT angiography with vol-
ume-rendering and multiplanar reconstruction
images is a comprehensive technique for vas-
cular evaluation in patients with TA [10, 16].
TA is usually treated with immunosup-
pression and corticosteroids in the acute
phase. Angioplasty, stent placement, or sur-
gical bypass grafting are performed in the
chronic stages [11] (Fig. 4).
Giant cell (temporal) arteritis is the most
common vasculitis and a chronic granulo-
matous disease of the large and medium ves-
sels [17–19]. GCA affects older patients (>
50 years old), with peak incidence in the 6th
through 8th decades of life, and with a pre-
dominance among women. The disease most
commonly involves the extracranial carotid
artery and its branches, including the super-
ficial temporal, vertebral, and ophthalmic
arteries [18]. Extracranial GCA has most
frequently been reported in the aortic arch
and the subclavian and axillary arteries [20–
23]. Temporal artery biopsy can show inva-
sion of the vessel wall by macrophages, lym-
phocytes, and plasma cells. Giant cells are
present, and the internal elastic membrane
is disrupted [21]. The adventitia containing
the vasa vasorum seems to be an important
site of inflammation, implicating a specific
immune response. Temporal artery biopsy
should be avoided if collateral flow is present.
GCA tends to cause long stenoses of the
middle to distal segments of the subclavian
and axillary arteries. Segments of stenosis
are often separated by normal segments, re-
sulting in so-called skip lesions. Aortic in-
volvement occurs in a significant percentage
of patients [24, 25]. Aneurysm formation
has also been described. IV DSA, CTA, and
MRA can be used to detect the arteriograph-
ic pattern of stenosis or occlusions with a
smooth tapered appearance in the subclavi-
an, axillary, and proximal brachial arteries.
CTA and MRA can also show vessel thick-
ening, indicating active disease and aneu-
rysmal lesions (Fig. 5). Positron emission
tomography (PET) can be used to monitor
disease activity of giant cell arteritis as well
as TA [26, 27].
Buerger disease (thromboangiitis oblit-
erans) is a nonatherosclerotic segmental in-
flammatory disease of small and medium
arteries [28, 29]. Buerger disease is accept-
ed as a definite vascular disease, with typi-
cal clinical presentation, history, and histo-
pathologic features [30]. This disease is an
endarteritis associated with activation of
macrophages or dendritic cells in the inti-
ma. Although inflammation involves all lay-
ers of the vessel wall, the normal vessel wall
structure remains intact [29]. Repeated at-
tacks usually result in complete obstruction
of the vessel. There is no eccentric lumen,
wall destruction, aneurysm formation, ather-
oma, or calcification, which helps to distin-
guish Buerger disease from other arteritides.
Buerger disease affects predominantly
young male smokers, with the age of onset
usually before 40–45 years [28–30]. Howev-
er, prevalence of the disease among women
is increasing. Most laboratory tests are nor-
mal in patients with active disease. Arterio-
graphic findings may be suggestive but are
not pathognomonic in diagnosis of thrombo-
angiitis obliterans. Changes typically involve
 CT Angiography of Upper Extremity Arterial Systems
the medium and small arteries localized dis-
tally to the elbow or knee, including occlu-
sions, luminal irregularities, and segmental
narrowing with smooth or irregular walls.
Findings include segmental occlusive lesions
(diseased arteries interspersed with normal-
appearing arteries) and more severe disease
distally with normal proximal arteries. Be-
fore occlusion, collateral vessels develop,
forming the characteristic corkscrew shape
(Martorell sign) (Fig. 6). These are also
known as “tree root” or “spider’s leg” col-
laterals [31]. It seems reasonable to assume
that the vessels represent pathologically wid-
ened vasa vasorum [29–31]. The corkscrew
appearance is the most specific finding in
Buerger disease, but it is not pathognomon-
ic. It may be present in any connective tis-
sue disease (e.g., systemic lupus erythema-
todes, scleroderma, and CREST [calcinosis,
Raynaud phenomenon, esophageal involve-
American Journal of Roentgenology 2013.201:753-763.
ment, sclerodactyly, and telangiectasia] syn-
drome,) in small-vessel obstructive disorders
(e.g., diabetes), and in patients using cocaine
or cannabis [32]. The occlusions usually are
bilateral, although symptoms may be isolat-
ed to one extremity.
Treatment consists of discontinuation of
smoking. The diffuse segmental involvement
and distal nature of the disease, together with
the lack of sufficient distal target vessels that
typifies the condition, usually make surgical
revascularization impossible. In individuals
with severe ischemia and an identifiable dis-
tal target vessel, bypass surgery with the use
of an autologous vein can be considered.
Small Artery Vasculitis in the
Upper Extremities
The small vessel vasculitides show an ob-
literative fibrosis that causes digital ischemia
and gangrene. CTA plays no significant role
in diagnosing these disorders other than rul-
ing out more proximal disease.
Raynaud phenomenon is characterized
by reversible vasospasm of the small and
medium arteries and is diagnosed with
catheter angiography following intraar-
terial injection of a vasodilator. Raynaud
disease is termed “primary vasospastic
disease” when there is no associated under-
lying disorder. Patients have an abnormally
strong vasospastic response to cold or emo-
tional stimuli with anatomically normal ar-
teries. Primary Raynaud disease typically
occurs in young women, is bilateral, has a
benign course, and requires only symptom-
atic treatment.
AJR:201, October 2013 755
Raynaud syndrome, which is also called
“secondary vasospastic disease,” may have
multiple causes, which result from trauma to
the vasculitis, as seen in systemic connective
tissue diseases [33, 34]. Brachial angiogra-
phy remains the reference standard meth-
od to delineate the vasculature of the hand
in Raynaud disease. It can accurately illus-
trate areas of narrowed vessels with very
poor flow in the digital vessels [33]. Angi-
ographic findings in patients with Raynaud
disease usually tend to be descriptive and are
not specific. The findings are characterized
by narrowing and tapering of the proper digi-
tal vessels. Small vessel involvement is char-
acteristic of connective tissue disorders, such
as scleroderma, CREST syndrome, system-
ic lupus erythematosus, rheumatoid arthritis,
mixed connective tissue disease, polymyosi-
tis, and dermatomyositis. CTA plays no role
in diagnosing these disorders other than rul-
ing out more proximal disease.
Behçet disease is a multisystemic inflam-
matory disorder that is chronic and relapsing
and is characterized by a classic triad of aph-
thous stomatitis, uveitis, and urogenital ul-
cerations [35]. The disease typically affects
young adults in the 2nd or 3rd decade of life
[18, 35]. There are no laboratory results that
are pathognomonic for Behçet syndrome;
consequently, the diagnosis is made on the
basis of the clinical findings [36].
The vasculitis can involve large and small
arteries, veins, arterioles, venules, and capillar-
ies. Arterial involvement occurs in fewer than
8% of patients with Behçet disease. Behçet dis-
ease associated with lesions in the large vessels
is referred to as vasculo–Behçet disease, which
includes venous or arterial occlusion and aneu-
rysm formation [18]. The pathologic findings
include arteritis and inflammatory obliterative
endarteritis of the vasa vasorum, with fibrotic
deterioration of the media and dilatation of the
vessel lumen [36, 37].
Radiation arteritis is a rare complication
of high-dose radiation therapy for underlying
malignancies, such as breast carcinoma and
lymphoma. Pathologic changes include inju-
ry to the vasa vasorum, fibrosis of the inter-
nal elastic membrane and periarterial fibro-
sis, and ischemic necrosis, hyalinization, and
thickening of the vessel wall. These changes
may only become apparent 5 years or more
after treatment. The angiographic appearance
of radiation-induced subclavian or axillary
arteriopathy may mimic primary atheroscle-
rotic disease, with focal occlusion or steno-
sis, and may appear as a vasculitis. Becker
et al. [38] showed that radiation arteriopathy
may manifest as occlusion, subocclusive scle-
rotic or atheromatous plaque, localized mu-
ral thrombus, aneurysm, or, rarely, spontane-
ous rupture. Transmural necrosis of the vessel
wall is also rare and may result in the forma-
tion of a false aneurysm [38]. Radiation arte-
ritis can be distinguished from other vascular
diseases by the clinical history and the extent
of the involved arterial segment.
Fibromuscular Dysplasia
Fibromuscular dysplasia is a nonathero-
sclerotic noninflammatory vascular disease
that usually involves medium and small ar-
teries, most commonly the renal, carotid,
and intracerebral arteries. Upper extrem-
ity fibromuscular dysplasia is rare, but cas-
es of fibromuscular dysplasia of the bra-
chial artery leading to ischemia have been
described. The most common type is medi-
al fibrosis, which has the typical “string-of-
beads” appearance [39] (Fig. 7).
Extrinsic Compression Syndromes
Thoracic outlet syndrome (TOS) refers to
compression of the neurovascular bundle as
it crosses through the thoracic outlet [40].
Patients commonly present with pain, tin-
gling, weakness, or other symptoms of the
ipsilateral upper extremity. The syndrome
may be caused by neurogenic, arterial, ve-
nous, or combined causes, although the neu-
rogenic cause is most common [41]. Venous
TOS is most commonly caused by compres-
sion of the subclavian vein by a skeletal or
soft-tissue abnormality, such as a cervical
rib or hypertrophied scalene muscle. Effort-
induced TOS, or Paget–von Schrötter syn-
drome, is a well-described acute variant of
venous TOS.
Arterial TOS is classically diagnosed by
DSA performed in arm abduction and in a
neutral position. Both CTA and MRA have
been shown to be able to make the diagno-
sis [41–43]. Treatment consists of removal of
the skeletal or soft-tissue abnormality, such
as resection of cervical ribs or the first rib,
and vascular reconstruction or thrombolysis,
if necessary (Fig. 8).
Brachial artery compression syndrome
is a rare cause of hand ischemia, typically
caused by compression of the brachial artery
in hyperextension at the elbow joint, due to
abnormal muscles, muscle hypertrophy, or
bone spurs [44].
Guyon canal is a fibro-osseus space in the
anteromedial portion of the wrist that con-

tains the ulnar neurovascular bundle, which
consists of the ulnar nerve, ulnar veins, and
ulnar artery. Guyon canal is the second most
common site of ulnar nerve entrapment [45].
There are many causes for ulnar entrapment
neuropathy at Guyon canal, including frac-
tures of the radius or pisiform bone or hook
of the hamate, gangliomas, cysts, ulnar ar-
tery aneurysm, and repetitive strain injury
[45, 46]. Ulnar artery involvement is pos-
sible, and there is overlap with hypothenar
hammer syndrome.
Hypothenar hammer syndrome common-
ly presents with pain, hypothenar mass, cold
intolerance, or unilateral ischemia of the
third through fifth digits in a patient with re-
petitive trauma to the hypothenar eminence,
such as mechanics, carpenters, construc-
tion workers, or athletes [47–49]. Additional
risk factors include underlying vasculitides,
smoking, and collagen vascular disease. The
American Journal of Roentgenology 2013.201:753-763.
repetitive trauma in these patients results in
aneurysm formation of the ulnar artery near
the hamate bone of the carpus (Fig. 9). Of-
ten, these ulnar arterial aneurysms result
in distal emboli and occlusion of segmen-
tal digital arteries or the distal ulnar artery
itself. The imaging evaluation for hypothe-
nar hammer syndrome may be performed
by duplex ultrasound, DSA, CTA, or MRA
[48, 50–52]. Treatment planning, however,
is commonly performed with CTA or MRA,
which provides additional anatomic infor-
mation. Rest from the repetitive activity,
smoking cessation, medical therapy with va-
sodilators, thrombolysis, and surgical bypass
are treatment options [48].
CTA can be used to evaluate the upper ex-
tremities for arteriovenous fistulas and arte-
riovenous malformations. Enlarged arteries
and veins are typical findings in these patho-
logic abnormalities (Fig. 10). CTA is partic-
ularly helpful to diagnose osseous involve-
ment [53–55].
Connective Tissue Disorders
Congenital connective tissue disorders,
such as Marfan, Ehlers-Danlos, and Loeys-
Dietz syndromes, are responsible for nonin-
flammatory degeneration of the vascular wall,
leading to aneurysm formation, dissection or
rupture. Marfan syndrome is a rare autosomal
dominant disorder that affects the cardiovas-
cular, musculoskeletal, and ocular systems,
and it may also affect the pulmonary and ner-
vous structures [56]. The underlying defect is
an abnormality of microfibrils in elastic tis-
sue throughout the body. The cardiovascular
756 AJR:201, October 2013
Bozlar et al.
complication typically seen in Marfan syn-
drome is aneurysmal dilatation of the aortic
root, which leads to premature death caused
by aortic rupture or dissection. Likewise, the
remaining aorta and its branches are vulnera-
ble to subsequent aneurysmal changes. Ehlers-
Danlos syndrome type 4 disease, the vascular
type, in which there is a defect in type 3 colla-
gen, is characterized by extremely friable ar-
teries that are prone to aneurysm formation,
dissection, arterial and venous rupture, and
organ rupture [57] (Fig. 11). Other clinical
features include easy bruisability, translucent
skin, characteristic facial features, and uter-
ine or gastrointestinal rupture [57, 58]. Loeys-
Dietz syndrome is typically characterized by
the triad of hypertelorism, cleft palate or bi-
fid uvula, and skeletal and vascular findings
[59]. Dilatation of the aortic root, at the lev-
el of the sinuses of Valsalva, is the most im-
portant clinical finding in patients with Loeys-­
Dietz syndrome and has been reported in 98%
of cases [59]. Approximately one half of indi-
viduals with Loeys-Dietz syndrome have an
aneurysm distant from the aortic root [60].
Arterial involvement is widespread in patients
with Loeys-Dietz syndrome; although all ar-
terial territories can be involved, the vessels in
the head and neck region are more frequently
affected, and aneurysm formation, dissection,
stenosis, and general tortuosity have been de-
scribed [59, 60]. For all these hereditary dis-
eases, the spectrum of vascular complications
is broad, and they have been located in many
arterial territories, including the arteries of
the upper extremities [61–63].
Preprocedural Planning and
Postprocedural Evaluation
CTA plays a significant role in the plan-
ning of complex arterial surgical recon-
structions where upper extremity arterial
mapping is needed [55]. This includes carot-
id-subclavian bypass grafts, upper extremi-
ty bypass grafts, as well as axillofemoral by-
pass grafts. Klein and colleagues [64] found
upper extremity CTA useful for planning mi-
crosurgical reconstructive surgery involving
free tissue flaps. CTA has also been shown to
aid surgeons in the assessment of the upper
extremity vasculature, specifically the radi-
al artery, in patients requiring aortocoronary
bypass grafting [65].
CTA is also used for vascular mapping
when planning and evaluating hemodialysis
access. Similar to complex extremity recon-
structions, critical evaluation of the extrem-
ity vasculature is essential to future success
of the vascular access, whether an arteriove-
nous fistula or an arteriovenous graft is cre-
ated. Traditionally, vascular mapping is per-
formed with duplex ultrasound, but CTA and
MRA may be performed for more anatom-
ic imaging. Complications of dialysis access
are typically diagnosed with DSA and ultra-
sound. However, CTA has also been shown
to reveal complications such as arterial steal,
aneurysm formation, stenoses, and occlu-
sions [66, 67] (Fig. 12).
CTA of the upper extremities is useful for
monitoring patency of bypass grafts and stents
of the upper extremity arteries, particularly the
intrathoracic portions (Figs. 8). Its results have
an impact on the choice of treatment of post-
surgical complications. As with other vascular
territories, upper extremity CTA is an effective
modality to monitor stents for complicating
features, such as migration, fracture, intimal
hyperplasia, or thrombosis (Fig. 13).
Conclusion
CT angiography has become an important
diagnostic imaging modality for the evalua-
tion of upper extremity vascular pathologic
abnormalities. The attractiveness of upper ex-
tremity CTA is its 24-hour availability, rap-
id acquisition, minimal invasiveness, and the
display of both vascular and musculoskeletal
structures. Upper extremity CTA shows ex-
cellent performance to the level of the wrist,
whereas the evaluation of the hand remains
the realm of DSA (and MRA) in our practice.
Acknowledgement
We gratefully acknowledge the contribu-
tion to this work by Lauren M. Hagspiel of the
College of Arts and Sciences at the University
of Virginia.
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Fig. 1—68-year-old woman with atherosclerosis and history of aortoiliac

occlusive disease necessitating axillofemoral bypass graft who presented with
numb pulseless left upper extremity.
A, Volume-rendered image shows axillofemoral bypass graft (arrow) with stenosis
proximal and distal to anastomosis in native left axillary artery (arrowheads). Note
calcified plaque in the proximal descending thoracic aorta, at the origin of the
great vessels, and in the left common carotid artery (asterisks).
B, Axial subvolume maximum intensity projection better outlines stenoses
(arrowheads). Axillofemoral bypass (asterisk) is depicted end-on.

A B

758 AJR:201, October 2013

 CT Angiography of Upper Extremity Arterial Systems

Fig. 2—63-year-old woman who underwent right
colectomy for adenocarcinoma of colon. During
postoperative period, she developed acute pain
and weakness in right upper extremity. Volume-
rendered CT angiography shows long occlusion
of brachial artery, which was caused by acute
American Journal of Roentgenology 2013.201:753-763.
Fig. 3—78-year-old woman with acute type A thoracic aortic dissection who
presented with acute chest pain and syncope. Physical examination revealed
weak right upper extremity pulse. CT angiography of right upper extremity, chest,
abdomen, and pelvis was performed to evaluate for aortic dissection and upper
extremity arterial pathology. Oblique multiplanar reconstruction image reveals
ascending aortic dissection, with intimal flap (arrowheads) covering origins of all

thromboembolism. supraaortic branch vessels.

A B
Fig. 4—49-year-old man in chronic phase of Takayasu disease involving arch and supraaortic vessels.
A, Volume-rendered image shows right subclavian artery aneurysm (arrow) and left subclavian artery stent (arrowhead) implanted for steno-occlusive disease.
B, Axial image shows concentric thickening (arrowheads) of wall of origins of all three supraaortic branches.

Fig. 5—64-year-old woman with giant cell arteritis

who presented with fever, malaise, and bilateral
upper extremity weakness. CT angiography using
axial curved multiplanar reconstruction algorithm
shows typical irregular wall thickening (arrowheads) of
bilateral axillary and subclavian arteries.

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 Bozlar et al.
American Journal of Roentgenology 2013.201:753-763.

A B
Fig. 6—29-year-old male heavy smoker with thromboangiitis obliterans who presented with ischemic
symptoms of both upper and lower extremities.
A, Upper extremity CT angiography (CTA) shows distal ulnar artery occlusion (short thick arrow) and distal
radial artery contour irregularity (arrowheads) in right upper extremity. Note typical corkscrew collaterals (long
thin arrow). Stenoocclusive disease was also present in left ulnar and interosseous arteries.
B, Posterior volume-rendered view of lower extremity CTA shows involvement of right (R) popliteal and
Fig. 7—50-year-old woman with history of embolic
trifurcation arteries and left (L) posterior tibial artery (arrowheads).
disease to left arm and fibromuscular dysplasia
involving bilateral carotid, renal, and external iliac
arteries (not shown) who also had involvement of left
brachial artery with medial fibrosis, which shows
typical “string-of-beads” sign (arrowheads).

A B
Fig. 8—17-year-old girl with thoracic outlet syndrome who was evaluated at outside institution for embolic event to left hand. She was found to have aneurysm of left
subclavian artery, which was subsequently treated with covered stent. Several months after procedure, patient presented to our institution with heaviness and coolness
of left arm and hand.
A, Volume-rendered image shows subclavian artery stent, with proximal occlusion (arrowhead) and presence of left cervical rib (single asterisk). First rib is marked with
double asterisks. Clavicle was excluded for clarity.
B, Curved multiplanar reconstruction of left subclavian artery shows completely thrombosed stent (asterisks). Patient underwent subclavian artery vein graft placement
and resection of left cervical and first ribs.
(Fig. 8 continues on next page)

760 AJR:201, October 2013

 CT Angiography of Upper Extremity Arterial Systems

Fig. 8 (continued)—17-year-old girl with thoracic

outlet syndrome who was evaluated at outside
institution for embolic event to left hand. She was
found to have aneurysm of left subclavian artery,
which was subsequently treated with covered stent.
Several months after procedure, patient presented
to our institution with heaviness and coolness of left
arm and hand.
C, Volume-rendered image shows vein graft
(asterisks) and resection of left cervical and first ribs.
D, Curved multiplanar reconstruction confirms vein
graft patency (asterisks).

C D

Fig. 9—50-year-old man with hypothenar hammer syndrome who presented

American Journal of Roentgenology 2013.201:753-763.

with persistent right hand cold intolerance and pallor on ulnar digits, with pain at
fingertips. His condition had been refractory to medical treatment.
A, Volume-rendered reconstruction shows occluded ulnar artery (between
arrowheads) at Guyon canal.
B, Axial CT angiography source image shows ulnar artery thrombosis with ulnar
artery aneurysm (between arrowheads). Ulnar artery reconstruction with right leg
saphenous vein autograft was performed, and patient became symptom free.

A B

Fig. 10—23-year-old
man with arteriovenous
malformation in right
axilla.
A, Volume-rendered image
shows arteriovenous
malformation and
anomalous high origin of
radial artery (arrowhead),
which is normal variant.
B, Maximum intensity
projection of upper
extremity CT angiography
shows malformation
(arrowhead), with lateral
thoracic artery as main
feeder, and early venous
drainage.
A B

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 Bozlar et al.

A B
Fig. 11—17-year-old boy with known diagnosis of Ehlers-Danlos syndrome type 4 who presented to emergency department with extremely painful acute onset swelling
of right axilla and pulseless right upper extremity.
A, CT of chest and upper extremity was performed. Unenhanced CT shows large right axillary hematoma (asterisk).
B, Maximum intensity projection CT angiography shows extravasation from spontaneously ruptured right axillary artery (arrow). Emergent proximal surgical ligation was
performed.
American Journal of Roentgenology 2013.201:753-763.

A B C
Fig. 12—23-year-old man with dialysis fistula who presented with reduced flows while undergoing hemodialysis and ischemic symptoms in fingers of left hand.
A, Upper extremity CT angiography volume-rendered view shows dialysis fistula with aneurysm formation (asterisk) on venous side.
B, Subvolume maximum intensity projection (MIP) shows patent arterial anastomosis but diseased radial artery (A) with occlusion distally (arrowheads). There was also
stenosis in vein (V) immediately distal to anastomosis (arrow).
C, More central subvolume MIP shows critical stenosis of left subclavian vein (arrow).

762 AJR:201, October 2013

 CT Angiography of Upper Extremity Arterial Systems

Fig. 13—59-year-old woman who underwent stent placement in left subclavian

artery at outside institution presented with recurrent left upper extremity
claudication. CT angiography shows stent fracture (arrow) and severe stenosis
(arrowheads) due to intimal hyperplasia.
American Journal of Roentgenology 2013.201:753-763.

F O R YO U R I N F O R M AT I O N
The reader’s attention is directed to a related article, titled “CT Angiography of the Upper Extremity
Arterial System: Part 1—Anatomy, Technique, and Use in Trauma Patients,” which begins on page 745.

AJR:201, October 2013 763