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RADIAL, ULNAR & BRACHIAL ARTERY OCCLUSIONS

Introduction

Vascular occlusion of the radial, ulnar, or brachial arteries describes any form of blockage that restricts blood flow through these vessels of the upper extremity. Occlusion of any of these arteries can be caused by a blood clot due to embolism or thrombosis, and certain types of occlusion result from surgical complications or other trauma. Although some cases of arterial occlusion are asymptomatic, many patients experience pain, paresthesia, and temperature and color changes of the digits, which typically interferes with hand functionality. Conservative interventions such as anticoagulants, thrombolytics, and lifestyle modifications may be appropriate for patients with mild or no symptoms, but surgery is often required for more severe cases, especially if acute complete occlusions.1,2

Pathophysiology

  • Radial artery occlusion (RAO) most commonly results from either radial artery endothelial injury or thrombus formation
    • Endothelial injury can occur from larger sheath sizes, arterial spasm, arterial puncture and/or direct injury
    • Thrombus formation is the result of inadequate anticoagulation, and inappropriate hemostasis, either prolonged, occlusive, or both3,4
    • RAO is a common complication of transradial approach (TRA) coronary angiography and interventions
      • In most cases, RAO occurs promptly after the TRA procedure and up to 50% of patients have spontaneous recanalization of the artery within 1–3 months3
      • Brachial artery occlusion (BAO) may also occur as a complication after catheterization procedures performed via the brachial artery5
  • Baseline patient characteristics such as body mass index and diabetes may influence the likelihood of RAO occurrence2
  • The most common cause of ulnar artery occlusion (UAO) is repetitive blunt trauma to the hypothenar eminence, which can result in complete thrombosis of the ulnar artery
    • In some cases, a space-occupying lesion such as a ganglion within the defined space of Guyon’s canal may compress and eventually thrombose the ulnar artery6
    • Ulnar artery thrombosis has acquired the name “hypothenar hammer syndrome” due to its frequent occurrence among laborers who use the palm of the hand as a hammer7
    • Other causes of vascular occlusion include atherosclerosis, proximal embolic events, systemic diseases (eg, collagen vascular disease, vasculitis), and hypercoagulable states

Related Anatomy

  • Ulnar artery
  • Radial artery
  • Brachial artery
  • Superficial palmar arch
  • Deep palmar arch
  • Princeps pollicis artery
  • Guyon’s canal
  • Palmaris brevis muscle
  • Hypothenar eminence
  • Hook of hamate
  • Arterial intima and endothelium

Incidence and Related Conditions

  • The incidence of RAO as a complication after TRA interventions ranges from 0.8–38%2
    • RAO is more common in females and elderly patients after TRA interventions2
    • One study found the prevalence of UAO to be 9.6% in men and 1% in women
      • UAO was most often found in the dominant hand of elderly men and was associated with an occupational history of repetitive palmar trauma8
      • Arteriosclerosis
      • Atherosclerosis
      • Raynaud’s phenomenon
      • Scleroderma
      • Buerger’s disease
      • Vasculitis
      • Renal disease
      • Congenital vascular anomalies

Differential Diagnosis

  • Arteriovenous fistula
  • Churg-Strauss disease
  • Buerger’s disease
  • CREST syndrome
  • Giant cell arteritis
  • Raynaud’s phenomenon
  • Scleroderma
  • Takayasu arteritis
  • Thoracic outlet syndrome
  • Wegener’s granulomatosis
  • Pediatric thromboembolism
ICD-10 Codes

  • RADIAL ARTERY OCCLUSION

    Diagnostic Guide Name

    RADIAL ARTERY OCCLUSION

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    RADIAL ARTERY OCCLUSIONI74.2   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Vascular Thrombosis
  • Brachial artery thrombosis causing severe right hand ischemia
    Brachial artery thrombosis causing severe right hand ischemia
  • Thumb and index tip ischemia after hypovolemic shock and radial artery cannulation
    Thumb and index tip ischemia after hypovolemic shock and radial artery cannulation
Pathoanatomy Photos and Related Diagrams
Upper Extremity Vascular System
  • Upper Extremity Arteries: 1. Radial and ulnar digital arteries; 2. Superficial palmar vascular arch; 3. Deep palmar vascular arch; 4. Radial recurrent artery; 5. Inferior ulnar collateral arteries.
    Upper Extremity Arteries: 1. Radial and ulnar digital arteries; 2. Superficial palmar vascular arch; 3. Deep palmar vascular arch; 4. Radial recurrent artery; 5. Inferior ulnar collateral arteries.
  • Upper Extremity Veins
    Upper Extremity Veins
Symptoms
Pain
Paresthesias, hypesthesia and dysesthesia
Pallor, cyanosis, and in severe cases digital ischemia and gangrene
Reduced upper extremity function sometimes to the point of paralysis
Decreased/absent radial or ulnar pulse
Raynaud’s phenomenon
Upper extremity weakness
Typical History

The typical patient is a 49-year-old male auto mechanic. The right-handed man had been repairing cars as his primary profession for more than 30 years, and throughout his career, he often used the hypothenar eminence of his right hand as a hammer-like device to secure certain car parts. Over time, this repeated trauma to the hypothenar evidence damaged the ulnar artery and resulted in UAO due to complete thrombosis. This occlusion went on to cause pain around the hook of hamate, as well as various sensory and temperature changes in his right hand, which severely impacted his ability to work on cars. These symptoms prompted the man to seek out treatment.  He was ultimately treated with excision of the thrombosed segment of the ulnar artery and vein grafting.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • Conservative treatment may be appropriate for certain cases of vascular occlusion when a patient is asymptomatic or symptom presentation is mild
  • All conservative interventions should also include careful observation to detect any progression or regression
  • Anticoagulants (eg, heparin, warfarin)
  • Thrombolytics (eg, alteplase, streptokinase)
  • Calcium channel blockers (eg, nifedipine, diltiazem, verapamil)
  • In chronic conditions, lifestyle modifications may be helpful
    • Reduced exposure to cold/protection during cold exposure
    • Smoking cessation
    • Avoid recurrent trauma/use of padded gloves
Operative
  • Surgery is indicated when conservative interventions fail to elicit improvements and for patients presenting with severe symptoms and acute marked ischemia.
  • The goal of surgical treatment is to increase arterial inflow to the affected digits
    • Embolectomy: recommended for brachial emboli in the absence of arterial injury and when closure can be accomplished without narrowing9
    • Arterial resection: resecting a thrombosed arterial segment constitutes a local sympathectomy, which may be accomplished by division of the terminal branches of the nerve of Henle for the ulnar artery.7
    • Arterial reconstruction
      • Combined with excision of involved segment, with or without a vein graft
      • Indicated for ulnar artery thrombosis with aneurysm, ischemia in multiple digits, or digital brachial index of <0.7
    • Arterial ligation indicated for digital brachial index of >0.7
    • Endovascular fibrinolysis indicated for ulnar artery thrombosis without aneurysm
    • Sympathectomy
Treatment Photos and Diagrams
Artery Thrombosis Excision and Vein Grafting
  • Ulnar artery thrombosis secondary hypothenar hammer syndrome
    Ulnar artery thrombosis secondary hypothenar hammer syndrome
  • Ulnar artery thrombosis post excision
    Ulnar artery thrombosis post excision
  • Ulnar artery thrombosis post vein grafting
    Ulnar artery thrombosis post vein grafting
Complications
  • Infection
  • Amputation
  • Permanent digital ischemia
  • Gangrene
  • Ulceration
  • Necrosis
Outcomes
  • One study found that the overall success rate of embolectomy for treating acute upper limb ischemia was between 85-90%5
  • Using careful hemostasis after surgery has been shown to reduce RAO by 59% at 24 hours and by 75% at 30 days compared to standard hemostasis10
  • Radial artery reconstruction has been identified as an effective treatment for symptomatic RAO11
Key Educational Points
  • Symptomatic RAO at the wrist is uncommon and, unlike UAO, its natural history and indications for conservative and surgical management are not well defined11
    • RAO is asymptomatic in most patients due to the hand’s dual blood supply and the usually rich network of collateral circulation; therefore, if the radial artery is occluded, blood supply of the hand can be maintained by the ulnar collateral circulation and RAO is a quiescent event3
  • The choice for repairing an injured brachial artery depends upon the nature and extent of the damage sustained: if complete transection has occurred, restoration of continuity must be achieved after trimming the arterial ends to excise damaged intima, especially if collateral flow is inadequate9
  • Regardless of which strategy is used, prompt treatment is usually needed for vascular occlusion of any artery that results in upper extremity ischemia, as failing to treat it can lead to permanent loss of function or amputation5
  • There has been a dramatic upsurge in TRA interventions worldwide, which highlights the need for preventive strategies to reduce the occurrence of RAO as a surgical complication4
  • Reverse Barbeau test
    • Ulnar artery is occluded and a pulse oximeter is placed on the ipsilateral thumb
    • An absence of plethysmographic waveforms is indicative of radial artery occlusion3
References

Cited

  1. Ologun GO, Bohan C, Lau T, et al. Acute Brachial Artery Occlusion in an Elderly Patient With Acute Myocardial Ischemia. Cureus 2017;9(9):e1700. PMID: 29159007
  2. Rashid M, Kwok CS, Pancholy S, et al. Radial Artery Occlusion After Transradial Interventions: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016;5(1).e002686. PMID: 26811162
  3. Avdikos G, Karatasakis A, Tsoumeleas A, et al. Radial artery occlusion after transradial coronary catheterization. Cardiovasc Diagn Ther 2017;7(3):305-316. PMID: 28567356
  4. Chandrasekhar J, Mehran R. Radial artery occlusion: preventing insult to injury. Catheter Cardiovasc Interv 2015;85(5):826-7. PMID: 25789731
  5. Lee SH, Choi NC, Jang IS, et al. Simultaneous event of brachial artery occlusion and acute embolic stroke. Am J Emerg Med 2015;33(3):477.e3-4. PMID: 25227978
  6. Monstrey SJ, Jones NF. Intermittent occlusion of the ulnar artery. J Hand Surg Br 1994;19(1):27-9. PMID: 8169472
  7. Zimmerman NB, Zimmerman SI, McClinton MA, et al. Long-term recovery following surgical treatment for ulnar artery occlusion. J Hand Surg Am 1994;19(1):17-21. PMID: 8169363
  8. Carpentier PH, Biro C, Jiguet M, Maricq HR. Prevalence, risk factors, and clinical correlates of ulnar artery occlusion in the general population. J Vasc Surg 2009;50(6):1333-9. PMID: 19837535
  9. Lambert M, Ball C, Hancock B. Management of acute brachial artery occlusion due to trauma or emboli. Br J Surg 1983;70(10):639-40. PMID: 6626927
  10. Amin H. Prevention of radial artery occlusion: it's the right thing to do. EuroIntervention 2015;11(7):731-3. PMID: 26603983
  11. Ruch DS, Aldridge M, Holden M, et al. Arterial reconstruction for radial artery occlusion. J Hand Surg Am 2000;25(2):282-90. PMID: 10722820

New Articles

  1. Avdikos G, Karatasakis A, Tsoumeleas A, et al. Radial artery occlusion after transradial coronary catheterization. Cardiovasc Diagn Ther 2017;7(3):305-316. PMID: 28567356
  2. Chandrasekhar J, Mehran R. Radial artery occlusion: preventing insult to injury. Catheter Cardiovasc Interv 2015;85(5):826-7. PMID: 25789731

Reviews

  1. Ologun GO, Bohan C, Lau T, et al. Acute Brachial Artery Occlusion in an Elderly Patient With Acute Myocardial Ischemia. Cureus 2017;9(9):e1700. PMID: 29159007
  2. Rashid M, Kwok CS, Pancholy S, et al. Radial Artery Occlusion After Transradial Interventions: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2016;5(1).e002686. PMID: 26811162

Classics

  1. Rossi NP, Ehrenhaft JL, Sensenig DM. Acute brachial artery occlusion. Ann Surg 1965;161:195-200. PMID: 14260015
  2. Cameron HC. Sudden Occlusion of the Right Brachial and Femoral Arteries in an Infant aged 10 days, with Gangrene of Arm and Leg; Recovery of Arm, Amputation at Thigh. Proc R Soc Med 1920;13:9-10. PMID: 19981383
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