CURRENT CONCEPTS
Vascular Insufficiency of the Upper Extremity
James P. Higgins, MD, Michael A. McClinton, MD
Vascular insufficiency of the upper extremity can be due to acute vascular injury, chronic
vasospastic disease, and occlusive disease. Its treatment requires a thorough understanding
of the vascular anatomy of the upper extremity, diagnostic modalities, and medical and
surgical management options. Promising advances continue to be made in surgical treatment
and medical therapy. (J Hand Surg 2010;35A:1545–1553. © 2010 Published by Elsevier Inc.
on behalf of the American Society for Surgery of the Hand.)
Key words Arterial injury, botulinum toxin, hypothenar hammer, Raynaud’s disease,
sympathectomy.
ANATOMY
The vascular anatomy of the upper extremity is well de-
fined. Knowledge of the intricacies of collateral vessel
flow and anatomic anomalies serve the hand surgeon well
in the assessment and treatment of vascular problems in
several areas along the course of major arteries.
As the brachial artery descends through the medial
brachium anterior to the intermuscular septum en route
to the antecubital fossa, it serves as the dominant blood
supply to the distal extremity. Just distal to the antecu-
bital crease, it bifurcates into the major vessels of the
forearm. From this point forward, the dominant vessels
serve the hand with the vascular reserve and compen-
sation inherent to a duplicative system. An occlusion or
transection of the brachial artery proximal to this bifur-
cation can result in catastrophic ischemia to the distal
limb. There are 3 major sources of collateral flow across
the elbow, including the deep brachial artery, which
passes posterior and lateral to the humerus in tandem
with the radial nerve and joins the radial artery distally;
the superior ulnar collateral artery, which passes poste-
rior to the medial epicondyle in tandem with the ulnar
From the Curtis National Hand Center, Baltimore, MD.
Received for publication March 15, 2010; accepted June 6, 2010.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: James P. Higgins, MD, c/o Anne Rupert Mattson, The Curtis National
Hand Center, Union Memorial Hospital, 3333 North Calvert Street #400, Baltimore, MD 21218;
e-mail: anne.mattson@medstar.net.
0363-5023/10/35A09-0031$36.00/0
doi:10.1016/j.jhsa.2010.06.011
nerve to join the ulnar artery distally; and the inferior
ulnar collateral artery, which passes anterior to the
medial epicondyle to join the ulnar artery distally.
These vessels can serve as a means of continued pro-
fusion of the limb despite occlusion of the brachial
artery at or above the elbow.
The radial artery is more superficial than the ulnar
artery in the proximal forearm, coursing deep to the bicip-
ital aponeurosis and brachioradialis and superficial to the
biceps tendon, pronator teres, flexor digitorum superficia-
lis, and flexor pollicis longus sequentially. Along this
course, it reaches the wrist flexion crease between the
flexor carpi radialis and brachioradialis tendons. The ulnar
artery is deeper in the forearm, beneath the pronator teres,
median nerve, and flexor digitorum superficialis muscle
bellies. Shortly after its departure from the brachial artery,
it branches off the common interosseous artery before
migrating onward to the superficial surface of the flexor
digitorum profundus muscle to join the ulnar nerve at the
junction of the middle and proximal thirds of the forearm.
These 2 structures run in tandem to reach the wrist flexion
crease immediately deep and radial to the flexor carpi
ulnaris tendon.
Variance in the path or source of the radial artery is
reported in up to 30% of patients. The most common
Current Concepts
variation is the high origin of the radial artery rising
from the brachial or axillary artery proximal to the
antecubital fossa. This is estimated to occur in 2.4% to
14.3% of extremities. Substantially less common vari-
ations include absence of the radial artery, duplication
of the radial artery, and superficial passage of the radial
©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1545
 1546 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY

artery above the tendons of the snuffbox. Variation in palmar and dorsal metacarpal arteries and common
the ulnar artery pathway or position is much less com- digital arteries. Studies of the anatomic variability of
monly seen (3% to 5%).1 this network demonstrate that the superficial palmar
Substantial investigative efforts have been focused arch is complete in more than 80% of patients, whereas
on determining which of these 2 vessels is of greater the deep palmar arch is complete in more than 90% of
import to perfusion of the hand. Although the ulnar patients.1 A complete arch is defined as one that dem-
artery is larger in the proximal forearm, the radial artery onstrates anastomoses between the vessels that consti-
is more often larger at the tute it. The superficial palmar
level of the wrist. It has been EDUCATIONAL OBJECTIVES arch has been the focus of the
speculated that this is be- ● Describe the vascular anatomy of the upper extremity. greatest number of studies in
cause the ulnar artery ● Discuss the concept of vessel dominance with reference to the radial and this area, and a wide variety
branches throughout the ulnar arteries. of classification systems
forearm axis, whereas the ra- ● State the factors to consider when deciding to repair or ligate a single have been created based on
dial artery passes with rela- vessel injury at the wrist. differences in the anatomic
tively less division to its des- ● List the long-term changes in the ulnar artery following radial artery har- makeup of the arch. The
tination at the hand. The size vest. most commonly encountered
dominance of the radial ar- ● Discuss the long-term effects of radial artery harvest. arch is one in which a super-
tery at the wrist has been ● ficial arch is “complete” via
Compare and contrast the various types of vascular conduits.
demonstrated in both cadav- communications between the
eric studies and duplex ultra- Earn up to 2 hours of CME credit per JHS issue when you read the related superficial volar branch of
sound findings.2,3 Although articles and take the online test. To pay the $20 fee and take this month’s the radial artery and the su-
the ulnar artery serves as the test, visit http://www.assh.org/professionals/jhs. perficial branch of the ulnar
source vessel for the superfi- artery in Guyon’s canal. A
cial palmar arch and the radial artery serves as the clinically relevant anatomic variant is the presence of a
source vessel for the deep palmar arch, there are myriad communication between a persistent median artery (an
anastomotic interconnections between these 2 systems. embryologic remnant that normally undergoes apopto-
Because the common digital arteries to the fingers arise sis during upper limb development) and the superficial
from the superficial palmar arch, it might seem logical palmar arch, which serves to complete the arch. This
that this would serve as the dominant source of perfu- was seen in 15.5% of specimens in a well-performed
sion to the hand. Early data from studies of pulse cadaveric study.7
volume plethysmography indicated that the radial artery An overview of the areas of greatest scientific in-
was more often critical for maintaining pulsatile digital quiry in upper extremity vascular anatomy in the last 10
blood flow.4,5 There are additional data pertaining to the years should include the multitude of studies examining
compensatory effects of radial artery harvest (ie, radial the radial aspect of the hand. All of these studies dem-
forearm flap or radial artery conduit harvest) on blood onstrate a great deal of variability in the first web space
flow dynamics to the hand, demonstrating increased as to the source vessels serving the thumb and index
size and flow velocities across the remaining vessels. 6 finger, as well as their communications with the ulnar-
These data would indicate that the vascular bed of the sided structures.
hand is a complex anatomic and physiologic entity that
might preclude the assignment of vessel dominance. ACUTE VASCULAR INJURY
The blood vessels in the hand communicate via 3 Acute vascular injury from penetrating trauma is a
major arches—2 palmar and one dorsal (excluding car- common cause of ischemia with less diagnostic uncer-
Current Concepts

pal arches). A great number of studies have elucidated
the extreme anatomic variance in this network of ves-
sels, particularly on the radial side of the hand. The
superficial palmar arch is a source of 3 or 4 common
digital arteries, whereas the deep palmar arch gives rise
to 3 to 4 palmar metacarpal arteries. The dorsal arch,
likewise, is the source vessel for the anatomically di-
verse dorsal metacarpal artery system. These 3 systems
communicate at the level of the arches themselves, as
well as along the pathway of the longitudinally oriented
tainty than chronic vaso-occlusive disease. Debate in
the literature regarding the indications for repair of
noncritical vessels, however, warrants discussion.
Repair or ligate?
The decision to repair a damaged vessel is clear when
critical ischemia is evident. However, in the setting of
adequate perfusion via collateral vessels, the decision is
more difficult. Intraoperative indicators that perfusion is
adequate include the following:

JHS 䉬 Vol A, September 

 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY
1. Good capillary refill of fingertips.
2. Audible Doppler signals at the digital tips.
3. Pulsatile retrograde flow, demonstrable from the
distal end of the transected vessel.
4. Quantitative assessment (digital plethysmography
or digital pressure readings). A digital brachial
index (DBI) of greater than 0.7 is thought to be
indicative of adequate perfusion.
In the absence of adequate perfusion, repair should
be pursued. Indeed, even in the setting of perceived
adequate perfusion (as determined by one of the indi-
cators listed earlier), some centers/surgeons might opt
to repair damaged or thrombosed/aneurysmal noncriti-
cal arteries. Reasons to consider reconstruction in this
setting would include the following:
1. To avoid the development of critical ischemia in
the future. Patients with asymptomatic ulnar artery
occlusion at the wrist might be considered asymp-
tomatic because of adequate collateral flow from
the radial artery. Subsequent thrombosis, injury, or
vascular disease to the radial artery or more distal
collateral vessels can convert this asymptomatic
chronic occlusion into an acute-on-chronic isch-
emic event. Many studies demonstrate the short-
term safety of radial artery harvest for coronary
artery bypass grafting, radial forearm flap harvest,
or ulnar forearm flap harvest. However, the loss of
one of the major vessels supplying the hand un-
doubtedly places the patient at high risk in the
setting of subsequent arterial occlusion or injury at
a different location. Furthermore, long-term fol-
low-up data of patients who had radial artery
harvest for coronary artery bypass grafting sug-
gest that compensatory increase in ulnar artery
blood flow can accelerate atherosclerosis. Nonin-
vasive studies of forearms with surgical absence
of the radial artery have demonstrated increased
thickening of the intima and medial layers of the
ulnar artery with a higher prevalence of athero-
sclerotic disease as compared to the ulnar artery in
the contralateral 2-vessel forearm.8
2. Symptoms of noncritical, inadequate perfusion. The
subclinical or poorly studied end points of upper
extremity perfusion include cold intolerance and re-
duced peripheral tissue perfusion (which can include
neural perfusion associated with symptoms of numb-
ness). These end points seem to defy quantitative
study but might be affected by the loss of dual-vessel
upper extremity blood supply. In a study of the
long-term effects of radial artery harvest and coro-
nary artery bypass grafting patients, normal perfu-
sion was demonstrated at rest; however, exercise-
induced transcutaneous oxygen desaturation was
noted in the hand, indicating that perhaps insufficient
perfusion can occur under demand.8
JHS 䉬 Vol A, September 
1547
Although the indication for vessel reconstruction is
obvious in the setting of critical ischemia, the need for
reconstruction of noncritical disease vessels remains
unclear. This is most commonly encountered in the
setting of acute arterial injury; however, the question
holds clinical significance in the arena of vaso-occlu-
sive disease, especially in the setting of noncritical
aneurysmal vessels (hypothenar hammer syndrome).
The trend appears to be in favor of restoring patients’
normal anatomy with surgical reconstruction. This
trend might be driven by the concerns mentioned
earlier and is also likely a result of improved micro-
surgical techniques that enable centers to perform
these procedures without substantially prolonging
surgical time.
CHRONIC VASCULAR INSUFFICIENCY
Sophisticated diagnostic tools have not diminished the
importance of a thorough medical history, seeking the
common and obscure causes of vascular insufficiency.
Careful questioning probes prescribed and over-the-
counter medications, coagulopathies, embolic condi-
tions, collagen vascular diseases, hand injury, history of
malignancy, and tobacco usage. Occupational and rec-
reational exposure to vibration or repetitive hand
trauma (hypothenar hammer syndrome) is identified.
Validated questionnaires such as the McCabe cold sen-
sitivity severity scale9 can provide quantitative initial
and follow-up evaluations.
A careful physical examination includes an as-
sessment of fingertips and fingernails, looking for
hallmarks of embolic and other types of chronic
ischemia. Timing the return of flow in Allen’s test
as recommended by Gelberman10 adds a quantita-
tive element to identifying arterial occlusion at the
wrist. The handheld Doppler is invaluable for in-
vestigating the blood flow through the radial and
ulnar arteries at the wrist and the superficial pal-
mar arterial arch in the hand, as well as assessing
distal arterial patency by digital Allen’s test. Non-
invasive vascular tests, including segmental arte-
rial pressure measurements, standardized as DBI,
and pulse volume recordings that measure actual
Current Concepts
arterial inflow and egress via volume changes in
the digits, are helpful for initial vascular assess-
ment and postoperative follow-up.11 Color duplex
imaging is noninvasive, cost efficient, and repeat-
able, and it is often the first test to evaluate masses
of the upper extremity located near vascular struc-
tures (ie, to differentiate volar wrist ganglion from
a radial artery aneurysm).12,13
 1548 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY
Vascular imaging
The computed tomography angiogram (CTA) contin-
ues to show promise as an alternative to contrast an-
giography. This technique does expose the patient to
radiation and requires intravenous dye, but it avoids the
need for intra-arterial catheterization. A recent study by
Anderson et al.14 investigated CTA in penetrating
trauma. Chang et al.15 studied 14 patients who had
complex upper extremity reconstruction and who were
evaluated by CTA before surgery. All studies illustrated
the pertinent anatomy, and the intraoperative vascular
findings confirmed the CTA in all cases. The planned
surgery for two of the patients was altered due to the
CTA findings.
Magnetic resonance angiography requires no ioniz-
ing radiation, does not induce vasospasm, and has no
renal side effects. Vascular detail is enhanced by the
administration of gadolinium. Magnetic resonance an-
giography is widely used in the lower extremity for
evaluation of peripheral vasculature, but its use has
been limited in the upper extremity by difficulty in
clearly demonstrating the fine detail of small and dis-
eased vessels that would be useful for evaluation of
chronic ischemia. Newer magnetic resonance imaging
technology holds the promise of a true alternative to
contrast angiography.11
Contrast arteriography has been and continues to be
the gold standard for visualizing the upper limb arterial
system. This modality can provide adequate detail to
plan distal hand and finger revascularization proce-
dures.13 Close collaboration with vascular surgery and
interventional radiology colleagues can assist in preop-
erative evaluation of patients with vascular insuffi-
ciency from both aneurysmal and thrombotic condi-
tions. Such collaboration expands our capabilities to
include angioplasty in the wrist and hand and intra-
arterial thrombolysis. These modalities can be helpful
for cases in which vascular reconstruction is not possi-
ble or to provide proximal or distal vessel patency
before surgical reconstruction of a wrist or palm arterial
defect. Review of real-time sequential images greatly
enhances the surgeon’s ability to estimate the extent of
Current Concepts
thrombosis and the quality of collateral flow. It is help-
ful for the hand surgeon and the interventional radiol-
ogy colleague to review the case together so that infor-
mation obtained at the time of the vascular study is not
missed when the static images are studied. The extent of
arterial occlusion is often overestimated when judged
by the absence of contrast seen in vessels proximal or
distal to the thrombosis. A nonvisualized superficial
arch might be erroneously deemed nonreconstructable,
whereas surgical exploration may yield a surprisingly
JHS 䉬 Vol A, September 
discrete lesion with a patent arch distal to the occlusion.
Arteriography should serve as a guide to the status of
the patient’s vascular insufficiency, requiring the sur-
geon to remain flexible during surgical exploration.
Vaso-occlusive disease
Ulnar artery thrombosis: Ulnar artery occlusion at the wrist
is the most common occlusive disorder of the upper
extremity. 16 In the absence of collagen vascular dis-
ease, this condition is far more common in men than in
women. Episodes of blunt trauma to the hand are often
the cause. This condition, referred to as hypothenar
hammer syndrome, occurs commonly in manual labor-
ers (eg, carpenters and auto body shop workers), espe-
cially those who smoke and those who use vibratory
tools. As the ulnar artery becomes occluded, the degree
of symptomatology depends in part on the extent to
which the radial artery supplies the ulnar digits. In
addition, patients can experience downstream emboli-
zation, resulting in intermittent episodes of digital isch-
emia. Patients usually present with cool, pale, ulcerated,
and painful fingers on the ulnar aspect of the hand.
Allen’s test generally confirms occlusion of the ulnar
artery. Patients can be treated conservatively with at-
tempts at cessation of cigarette smoking, avoidance of
extreme cold, or vasodilator therapy. Patients with crit-
ical ischemia are generally evaluated with noninvasive
vascular testing to obtain a baseline and gauge the
extent of reduced digital arterial flow. If the DBI is
⬍0.7, arteriography can be used to obtain a detailed
assessment of outflow to the hand and digits.13 A cork-
screw appearance of the ulnar artery on the arteriogram
indicates alternating fibrosis and dilatation and has been
found to be an early sign of ulnar artery thrombosis.17
Recent thrombosis might be amenable to thrombolytic
therapy administered through the indwelling catheter.
Usually, there has been chronic damage to the ulnar
artery, precluding successful chemical treatment, and
vascular reconstruction rather than simple ligation
should be done18 when the DBI is ⬍0.7.
The occluded ulnar artery should be approached as a
revascularization of the hand rather than strictly a by-
pass of the ulnar artery. With this in mind, the ulnar
artery is explored proximal to the wrist and followed
until the beginning of the occluded segment is visual-
ized. Koman has pointed out that there is often a patent
collateral branch leaving the ulnar artery, just proximal
to the occluded segment.12 Keeping the anastomosis
proximal to this branch will provide good proximal
inflow. The ulnar artery is dissected through Guyon’s
canal to the superficial palmar arterial arch and its 3
common digital arteries. To investigate the status of
 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY
these vessels, we generally perform a palmar, periarte-
rial sympathectomy that extends for a distance along
the common digital arteries. After an assessment of the
extent of vascular damage is complete, a bypass conduit
is selected.
Vascular conduits: Reversed vein grafts are the most
widely used conduit. Reversal is necessary to ensure
that the valves permit unobstructed antegrade flow.
Typical donor sites include the volar wrist (to replace
proper digital vessels), the dorsal hand or wrist (to
replace the superficial arch or common digital vessels),
and the greater or lesser saphenous veins (to replace
brachial ulnar or radial segments).
In situ vein grafts have been used in some centers,
particularly when inflow is sought from the antecubital
fossa or higher. In this setting, a roughly parallel cours-
ing vein is transected proximally and distally and anas-
tomosed to adjacent arterial target vessels to provide a
conduit to bypass the diseased arterial segment. The
advantage of this technique is that the vein will provide
an appropriate size taper, being larger on the proximal
side and smaller on the distal side. This technique
requires ligation of branches along the pathway of the
vessel to ensure that the flow is directed distally, as well
as disruption of the valves with valvulotome to permit
antegrade flow. This technique can be used when the
segment requiring bypass does not extend beyond the
wrist flexion crease. Some surgeons will use this in
conjunction with another conduit (reverse vein graft) to
reach beyond the wrist flexion crease distally.
Arterial grafts have become increasingly popular be-
cause of the handling characteristics of the artery and
the appropriate size taper. Expendable arterial graft sites
are more limited than vein harvest sites, but popular
sites are familiar to the reconstructive surgeon because
they are often sites used for free tissue transfer harvest.
These vessels will often provide branching patterns
useful for reconstruction of the superficial palmar arch
and its distal branches. These grafts are limited in their
length and are thus more appropriate for a shorter
segment reconstruction starting at the distal forearm
and extending to the superficial palmar arch. Com-
monly used donor sites include the deep inferior epi-
gastric artery (demonstrated to provide 14 cm of usable
length),19 the thoracodorsal artery (shown to be some-
what longer and providing a greater branching pat-
tern),20 and the descending branch of the lateral circum-
flexed femoral artery (which appears to be slightly
shorter in length but provides great ease of harvest). The
medical literature on coronary artery bypass grafts is
replete with reports demonstrating improved patency of
arterial grafts over vein grafts. In the field of vaso-
JHS 䉬 Vol A, September 
1549
occlusive disease of the upper extremity, a prospective
trial comparing arterial conduits versus more conven-
tional venous conduits is needed. We find these grafts
much more suitable for bypass into small distal vessels
compared to reversed vein grafts. Arterial grafts have
become the conduit of choice in our center.
Radial artery thrombosis
The radial artery can be thrombosed at the wrist level
following arterial cannulation for arterial pressure mon-
itoring. It can also be thrombosed at or just distal to
the anatomic snuffbox. In addition, there is a location
for thrombosis of the radial artery from repetitive
trauma that has been termed thenar hammer syn-
drome.21 The thrombosis occurs in the palm of the hand
over the thenar eminence and is diagnosed by emboli-
zation to the digits. In this location, Allen’s test would
not indicate occlusion of the radial artery. In cases of
suspected radial artery thrombosis, arteriography is
used to demonstrate the extent of proximal thrombosis
and an indication of arterial outflow distally. Explora-
tion of the radial artery generally begins at the wrist
level. The first dorsal extensor tendon compartment is
opened, and the radial artery is identified passing be-
neath it. The radial artery is then followed toward the
thumb/index webspace, where it dives into the muscu-
lature of this web space and branches to the thumb and
deep palmar arterial arch. Division of the first dorsal
interosseous and adductor pollicis muscle fibers pro-
vides wide exposure of the vascular structures within.
Often, arterial bypass requires separate anastomoses to
the palmar arterial supply in the thumb and the deep
palmar arterial arch. There are many patients whose
hands have been successfully revascularized via the
deep palmar arterial arch only.
Arterial aneurysms
Aneurysms comprise the majority of vascular tumors of
the upper extremity. Just as ulnar artery thrombosis is
the most common occlusive condition of the hand and
wrist, the ulnar artery is the most common site for
arterial aneurysms of the upper extremity. Aneurysms
can be true aneurysms involving all 3 layers of the
arterial wall. Much more commonly, pseudoaneurysms
Current Concepts
are basically hematomas adjacent to the injured arteries
that become cannulated by blood flow from the adja-
cent artery and, as a consequence, pulsatile. All upper
extremity aneurysms should be resected due to the risk
of downstream emboli from these tumors.13 These an-
eurysms range in size from nonpalpable to large, visible
tumors with palpable thrill. Color duplex imaging is a
rapid and noninvasive technique for identification of the
 1550 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY
tumor, but arteriography should be used to determine
whether downstream embolization has occurred and is
affecting perfusion to the fingers.
Exploration of ulnar aneurysms is similar to that
described for ulnar artery thrombosis. The ulnar artery
proximal and distal to the aneurysm may be of good
quality, and primary repair might be possible. After the
aneurysm is excised, one should be prepared to carry
out a bypass reconstruction if the amount of damaged
vessel precludes end-to-end repair. Komorowska-Timek
et al.22 described ultrasound-guided percutaneous
injection of thrombin into 3-cm radial artery and
2.5-cm ulnar artery pseudoaneurysms with success-
ful thrombosis and ablation of these aneurysms with-
out surgical intervention.
Aneurysms can be found in the radial artery. They
are generally not considered to result from repetitive
trauma in their most common location dorsally on the
hand. Unlike aneurysms of the ulnar artery, radial artery
aneurysms do not generally cause arterial occlusion;
hence, Allen’s test might demonstrate flow through the
radial artery. This finding should not deter further in-
vestigation. Color duplex imaging, CTA, or magnetic
resonance angiography may demonstrate the aneurysm.
Percutaneous thrombin injection might be possible with
careful ultrasound guidance. Excision of the aneurys-
mal segment and arterial repair/reconstruction is pref-
erable.
Digital artery aneurysms are uncommon and are
usually mistaken for benign nonvascular tumors of the
digits. These aneurysms generally do not pulsate. They
can be tender, and they can be a source of distal em-
bolization. Before the aneurysm is excised, an atrau-
matic microvascular clamp can be applied to the prox-
imal artery to determine whether the affected artery is
critical to digit perfusion with the tourniquet deflated.
Arterial repair/reconstruction with the operating micro-
scope might be required in the setting of inadequate
contralateral digital arterial perfusion.
Arteritis
Arteritis is an acute or chronic inflammatory change in
Current Concepts
the walls of small, medium, and large arteries, second-
ary to systemic disease. These conditions are uncom-
mon but should be kept in mind when more common
causes of vascular insufficiency are not detected. Pa-
tients can present with systemic symptoms such as
fever, arthralgias, weight loss, and skin lesions. Labo-
ratory investigation would include serology studies
such as sedimentation rate, immunoglobulin screening,
connective tissue disease screening, and evaluation for
coagulopathies. Collagen vascular diseases result in an-
JHS 䉬 Vol A, September 
tigen antibody complex deposition in digital vessels and
can lead to digital thickening and occlusion conditions
such as rheumatoid arthritis, systemic lupus erythema-
tosus, and scleroderma (CREST syndrome). Less com-
mon conditions that should be kept in mind when
patients present with vascular insufficiency are polyar-
teritis nodosa; various blood dyscrasias, including poly-
cythemia vera and vasculitis secondary to medications;
and hypersensitivity vasculitis. Treatment of many of
these conditions is beyond the expertise of a hand
surgeon and will require rheumatology consultation.
Berger’s disease or thromboangiitis obliterans12,13 is
a vasculitis involving small- and medium-sized arteries
and veins. This condition affects a younger age group
than atherosclerotic occlusive disease, specifically pa-
tients between the ages of 20 and 50 years. This con-
dition primarily involves the lower extremities, but in
15% to 20% of patients, the upper extremity is also
involved. Patients present with intermittent claudica-
tion, recurrent sepsis, and migratory thrombophlebitis.
Pain can be severe. The trigger for this condition ap-
pears to be tobacco use. Conservative management is
centered on cessation of tobacco use. In patients with
ulceration and fixed ischemia of the upper extremity,
usually the distal vessels, arteriography should be used
to search for arterial occlusion that might respond to
vascular bypass grafting. If the arteriogram is not fa-
vorable for arterial reconstruction, these patients can be
helped by salvage procedures such as arterialization of
the venous system by long vein grafts or in situ arteri-
alization of the venous system with division of the
valves, rendering them incompetent and allowing for
reversed blood flow. Surgical sympathectomy at the
palmar digital level has been used, but we have not
found this to be effective for patients with Berger’s
disease.
Vasospastic disease
Vasospastic disease is inappropriate, reversible vascular
constriction in the distal extremities in response to a
variety of stimuli, most commonly cold or emotional
stress. Terminology for this condition can be confusing.
Koman has described 4 groups of patients with vaso-
spastic symptoms.12 Group 1 (Raynaud’s disease) in-
volves primary vasospastic disease. These patients have
vasospastic symptoms without underlying secondary
systemic disease or occlusive disease. Group 2 involves
vasospastic disease secondary to underlying collagen
vascular disease. Group 3 involves vasospasm second-
ary to occlusive disease. These patients have non-
reversible structural arterial issues. Group 4 involves
vasospasm secondary to an identifiable cause with
 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY
underlying normal arterial structure. Primary vaso-
spastic disease can be termed Raynaud’s disease or
primary Raynaud’s phenomenon. Secondary vaso-
spastic disease has been termed Raynaud’s syndrome
or secondary Raynaud’s phenomenon.
Primary vasospastic disease: Patients with primary vaso-
spastic disease rarely develop ulcerations or digit-
threatening ischemia.23 Women comprise the majority
(80%) of these patients. The condition can be inherited.
The age of onset is typically in the second or third
decade. The condition must be present for 2 years
without appearance of an underlying systemic condition
to be termed primary vasospasm. The vasospasm is
usually bilateral and tends to involve both upper and
lower extremities. Underlying secondary causes are not
present. Noninvasive vascular testing with stress, such
as submerging in cold water or placement in a cold
environment, quantifies the degree of vasospasm. After
underlying conditions are ruled out, this disease carries
a relatively benign prognosis and treatment is initiated
nonsurgically, including minimizing cold exposure,
avoiding tobacco, and avoiding medications known to
cause vasoconstriction. Treatment begins with the long-
acting form of nifedipine at 30 mg one to 3 times per
day. Botulinum toxin A can provide relief that can last
several months (described later). These patients might
benefit from surgical sympathectomy at the digital
level. When being evaluated for this surgery, patients
should first have cold stress testing, followed by local
anesthetic blockade of the affected digit and repeated
cold stress testing. If local anesthetic blockade stops the
vasospastic response, surgical sympathectomy is often
helpful.
Secondary vasospastic disease: Secondary vasospastic dis-
ease groups (Koman groups 2 and 3) are associated
with many disorders. Collagen vascular disease, espe-
cially scleroderma, is the most common cause, in our
experience. Unilateral vasospasm should prompt the
surgeon to consider thoracic outlet syndrome with re-
current microemboli to the hand initiating vasospastic
symptoms or a more distal occlusive disorder of the
radial or ulnar arteries. Vibration white finger is sec-
ondary vasospastic disease caused by the use of tools
such as power saws and pneumatic drills and hammers.
Other causes include heavy metal intoxication, certain
medications, coagulopathies, and metastatic disease, in-
cluding multiple myeloma.
An investigation of the structural integrity of the
arterial system from the great vessels to the digital
arteries is important for identifying treatable causes of
secondary vasospastic disease. Assuming that patients
with known collagen vascular disease or diagnosed
JHS 䉬 Vol A, September 
1551
Raynaud’s disease are not surgically correctable can
cause the surgeon to overlook correctable causes of
secondary vasospasm. By the time patients with colla-
gen vascular disease develop ulcerations or digit-threat-
ening ischemia, 2/3 of them have ulnar artery throm-
bosis at the wrist. These patients can have substantial
and long-term improvement in the vascular status of
their hands with arterial bypass procedures.
In our center, patients with secondary vasospasm are
evaluated with angiography. In those patients demon-
strating arterial thrombosis with adequate proximal in-
flow on arteriography, an exploration and attempted
arterial reconstruction is pursued. Patients who would
appear to have no evidence on angiography of arterial
outflow at the palm or digital level might, at the time of
the surgical exploration, have a patent superficial pal-
mar arterial arch and common digital arteries to serve as
target vessels for revascularization. A periarterial sym-
pathectomy can also serve as a useful tool to dilate
distal vessels in the palm and digits for microsurgical
reconstruction.
Cervical thoracic sympathectomy has been disap-
pointing in the treatment of upper extremity vasospastic
disease. Initially described by Flatt and subsequently
modified by Wilgis and Koman,12,13 surgical digital
sympathectomy has become standardized in patients
with primary vasospastic disease involving a single
digit. A palmar zigzag incision beginning in the distal
palm and extending to the proximal interphalangeal
joint of the involved finger is followed by separation of
digital arteries from digital nerves and division of dig-
ital nerve branches to the arteries. Under the operating
microscope, adventitia is stripped from the digital ves-
sels for a distance of at least one cm and generally up to
2 cm. In patients with chronic vasospasm secondary to
collagen vascular disease, periarterial adventitial strip-
ping is carried out to achieve sympathectomy of the
ulnar 4 digits and the thumb, if it is involved. This
sympathectomy, as described by Koman, includes 2 cm
of stripping over the radial and ulnar arteries at the wrist
and stripping of the dorsoradial artery distal to the
snuffbox on the dorsum of the hand if the thumb is
involved. Either the ulnar artery incision at the wrist is
extended into and across the palm or a separate trans-
Current Concepts
verse incision is made in the mid-palm to expose the
superficial arterial arch. The arch is stripped over its
entire distance, the origins of the 3 common digital
arteries are exposed, and periarterial sympathectomy is
carried out along these vessels for at least one cm.
Palmar and digital sympathectomy in collagen vascular
patients must be viewed as a palliative procedure be-
cause the disease is ongoing. Hartzell et al.24 have
 1552 VASCULAR INSUFFICIENCY OF THE UPPER EXTREMITY
compared long-term results for periarterial sympathec-
tomy in 2 groups of patients: those with autoimmune
disease and those with generalized arteriosclerosis. At
an average follow-up of 96 months, the autoimmune
group had more ulcers completely healed (28/42) and
fewer new ulcers when compared to the arteriosclerotic
group (2/17). Amputations were necessary in 26% of
the autoimmune group compared to almost 60% of the
arteriosclerotic group.
BOTULINUM TOXIN A
The use of botulinum toxin A in upper extremity sur-
gery is not new. Its effects as a skeletal muscle paralytic
have been used for the treatment of spasticity in the
setting of stroke, paraplegia, and dystonia. It has also
been used as a means of protecting flexor tendon repairs
during the duration of its effects on the proximal muscle
belly. Elsewhere in the body, it has been used for
muscular imbalance, including torticollis, blepharo-
spasm, and strabismus. It has been used in several other
settings, harnessing its difficult-to-explain, myriad ac-
tions. It has been used for the treatment of migraines,
hyperhidrosis, and Frey’s syndrome. Perhaps its most
recently expanding use in upper extremity surgery is for
the treatment of vasospasm (primary or secondary). Its
initial description for use in Raynaud’s phenomenon
was a report of its effect on 2 patients treated in Austria
that demonstrated symptomatic relief. These patients
were given markedly different doses and demonstrated
relief in 3 days and one week, respectively. This initial
report provided no long-term follow-up.25 The first
report in the American literature in 2007 provided 6- to
30-month follow-up on 11 patients. They were demon-
strated to have Raynaud’s phenomenon in the setting of
connective tissue disorders. All patients were screened
with arteriograms before surgery and noted to have no
occlusive disease proximal to the wrist. These patients
received 100 units of botulinum toxin A per hand. All
patients demonstrated pain relief in 24 to 48 hours. In 9
of the 11 patients, soft tissue ulceration healed. Some of
the patients required repeat injections 3 to 8 months
after the initial injection.26 In 2009, Neumeister et al.
Current Concepts
studied 19 patients with Raynaud’s phenomenon. All
patients had magnetic resonance angiograms or contrast
angiography to rule out proximal occlusive disease.
Patients were provided either 50 or 100 units of botu-
linum toxin A per hand. Of these patients, 63% required
more than one injection, 84% reported pain reduction,
and most of them reported that this occurred immedi-
ately after injection. Objectively, later Doppler scan-
ning demonstrated increased perfusion of the digits in
10/14 patients. These patients were studied just before
JHS 䉬 Vol A, September 
and within 30 minutes after the botulinum toxin A
injections. The effects of the botulinum toxin A ap-
peared to last longer than 12 months. One hundred
percent of the digital ulcers healed within 60 days. This
study shed more light on the efficacy of botulinum toxin
A in digital vasospasm and brought into question our
understanding of the mechanism of this action. The
observations in this study of the immediacy and dura-
tion of the action of the botulinum toxin A suggest that
perhaps its mechanism of action is multifactorial and
more complex than previously understood.27
Other studies have also reported improvement in
symptoms of pain in patients with vascular ischemia by
using botulinum toxin A. However, the studies thus far
have not included prospective, controlled trials. The
reports thus far include patients with a number of dif-
ferent collagen vascular diseases, and the doses pro-
vided vary widely in their concentration, magnitude,
and distribution throughout the hand. The studies report
variable numbers of treatments for these patients, and
the outcome end points include subjective pain im-
provement, assessment of the color of the digits, and
other end points that are difficult to quantify.
The initial reports are so promising, however, that
the use of botulinum toxin A for this indication is
becoming progressively more popular as a low-
morbidity, noninvasive option for vasospastic disease.
Remaining areas of investigation include the exact
mechanism of action, the appropriate dose and dosing
frequency, and the efficacy relative to surgical periar-
terial sympathectomy. Likewise, the exact indications
under the umbrella of upper extremity ischemia must
be further defined. Although our conventional knowl-
edge of action of botulinum toxin A would lead us to
believe that only true vasospastic disease would dem-
onstrate clinical benefit from botulinum toxin A, it
might be possible that botulinum toxin A will prove
useful in other settings. These could include treatment
of downstream vasospasm in identified large vessel
occlusive disease, posttraumatic digital cold intoler-
ance, and adjuvant intraoperative chemical palmar sym-
patholysis in the setting of more proximal bypass graft-
ing.
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JOURNAL CME QUESTIONS
Vascular Insufficiency of the Upper Extremity
In the setting of an acute vascular injury, what
intraoperative findings indicate that perfusion is
adequate?
a. Good capillary refill of fingertips
b. Audible Doppler signals at the digital tips
c. Pulsatile retrograde flow demonstrable from the
distal end of the transected vessel
d. A digital brachial index (DBI) of greater than 0.7
e. All of the above
To take the online test and receive CME credit, go to http://www.assh.org/professionals/jhs.
JHS 䉬 Vol A, September 
1553
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traumatic ulnar artery thrombosis: outcome of arterial reconstruction
using reverse interpositional vein grafting at 2 years minimum fol-
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What are the long-term effects of radial artery
harvest?
a. Thickening of the intima and medial layers of the
ulnar artery and less perfusion during exercise
b. Normal perfusion at rest and during exercise
c. Resurgence of the median artery
d. Emboli
e. Unknown
Current Concepts