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Arterial Supply of upper limb Dr Ashraf Hussain Vascular system • The vascular system plays the critical role of • Delivering nutrients and • Clearing metabolic waste products from peripheral tissues • Maintaining systemic core temperature. Vascular flow Vascular flow is controlled by various processes, including • Vessel anatomy • Vascular tone, which is controlled by neuroendocrine hormones along with autonomic nervous influence • End-organ metabolic requirements. • Upper extremity vascular disorders are less common than lower extremity disorders, Causes of vascular compromise • Acute trauma • Repetitive microtrauma • Systemic disease processes involving metabolic and/or autoimmune processes. • CASE 24: Hunter with bullet injury of right arm • Sher Dil • 28 years old • Male • Computer Programmer • Presenting Complaints: • Bullet injury right arm for 3 hours History Of Presenting Complaints: • Patient was in his usual state of health and hunting ducks with his friends 3 hours ago. After shooting at a flock of duck and successfully hitting one, he went to collect his prize. While picking up the shot duck, it resisted and in the commotion, his gun went off and injured his right arm. He fell unconscious and was later taken to the local clinic by accompanying hunters. There initial bandage was done and he was referred to a tertiary care hospital. He is complaining of severe pain in his arm, forearm and right hand. He received some analgesics at the local clinic but the pain is worsening. Physical Examination: • A young man lying on couch, in severe distress due to pain, well oriented in time, place and person. • • ABCDE of trauma protocol done • BP: 100/90mmHg • PULSE: 110/min • TEMP. A/F • R/R: 20/min Musculoskeletal Examination: • The right arm is bandaged, soaked with blood, forearm and hand appears dusky colored, pale and colder as compared to left side. On removing the bandage, wound of entry on medial side of mid arm with exit wound on lateral side. There is swelling of the arm with absent distal pulses. • • • • • • Respiratory System: Normal Cardiovascular System: Normal Abdomen: Normal Investigations: CBC and Blood Grouping sent. X-RAY Right Arm AP LAT views ordered. Cervical rib The axillary artery is separated into three parts by the pectoralis minor muscle, which crosses anteriorly to the vessel : • The first part is proximal to pectoralis minor; • The second part is posterior to pectoralis minor; • The third part is distal to pectoralis minor. Generally, six branches arise from the axillary artery: • One branch, the superior thoracic artery, originates from the first part; • Two branches, the thoraco-acromial artery and the lateral thoracic artery, originate from the second part; • Three branches, the subscapular artery, the anterior circumflex humeral artery, and the posterior circumflex humeral artery, originate from the third part Branches of the axillary artery. Brachial artery Brachial artery Branches. Arteries of the anterior compartment of the forearm. • In approximately 80% of patients, the deep and superficial palmar arches are connected and are referred to as complete. This results in a dual perfusion supply to the common and proper digital vessels. This is an important attribute of hand vascular architecture, providing collateral blood flow in the event of vascular pathology affecting one of these palmar arches. Superficial palmar arch. Arterial supply of the hand. Deep palmar arch. Where to take peripheral artery pulses in the upper limb. • Allen's test : To test for adequate anastomoses between the radial and ulnar arteries, compress both the radial and ulnar arteries at the wrist, then release pressure from one or the other, and determine the filling pattern of the hand. If there is little connection between the deep and superficial palmar arteries only the thumb and lateral side of the index finger will fill with blood (become red) when pressure on the radial artery alone is released. Trauma to the arteries of the upper limb The arterial supply to the upper limb is particularly susceptible to trauma in places where it is relatively fixed or in a subcutaneous position. • Fracture of rib I • Anterior dislocation of the humeral head Cathater in right axillary artery • Angiogram showing occlusion of • right ulnar artery, as well as digital occlusion • Symptomatic upper extremity arterial occlusive disease is uncommon because of the abundant collateral network and the infrequency of atherosclerosis in the upper extremity digital ischemia • The patient’s history may include the following: Arm fatigue upon exercise (ie, subclavian artery occlusion) • Vertebrobasilar insufficiency (ie, subclavian steal) • Rest pain that involves hand and digits • Digital gangrene • Raynaud syndrome (eg, color changes—white, blue, red or white, red, blue) • Smoking history • Occupational and recreational history (eg, baseball pitcher, tennis player, handballer, carpenter) • Drug ergots (peripheral vasoconstrictors used in the treatment of shock [eg, dopamine, adrenaline]) An arteriogram of the aortic arch that demonstrates the (1) brachiocephalic vessel, (2) the right subclavian, (3) the right carotid, (4) the left carotid, and (5) the left subclavian. These are normal findings. Brachial segment that demonstrates a high take-off of the radial artery from the mid brachial artery. Forearm vessels in a patient with distal embolization that demonstrate (1) radial artery, (2) interosseous artery, and (3) ulnar artery. (The ulnar artery demonstrates distal occlusion.) Distal ulnar artery occlusion and proximal radial artery occlusion with obliteration of the superficial palmar arch from distal embolization . Digital subtraction angiogram that demonstrates a normal subclavian axillary brachial segment with the arm at the patient's side Angiogram of upper extremity. The top is in a normal position. The bottom is in a hyperabducted position (arrow indicates area of stenosis).