Arterial Supply of upper limb

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Arterial Supply of upper limb

• Dr Ashraf Hussain

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Vascular system

• The vascular system plays the critical role of
• Delivering nutrients and
• Clearing metabolic waste products from peripheral
  tissues
• Maintaining systemic core temperature.

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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.

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• Upper extremity vascular disorders are less
  common than lower extremity disorders,

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Causes of vascular compromise

• Acute trauma
• Repetitive microtrauma
• Systemic disease processes involving metabolic
  and/or autoimmune processes.

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• 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

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• 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.

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• Physical Examination
• A young man lying on couch, in severe distress
  due to pain, well oriented in time, place and
  person.
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• ABCDE of trauma protocol done
• BP 100/90mmHg
• PULSE 110/min
• TEMP. A/F
• R/R 20/min

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• 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.

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• Respiratory System Normal
• Cardiovascular System Normal
• Abdomen Normal
• Investigations
• CBC and Blood Grouping sent.
• X-RAY Right Arm AP LAT views ordered.

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Cervical rib
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• 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.

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• 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

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Branches of the axillary artery.
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Brachial artery
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Brachial artery Branches.
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Arteries of the anterior compartment of the
forearm.
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• 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.

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Superficial palmar arch.
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Arterial supply of the hand.
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Deep palmar arch.
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Where to take peripheral artery pulses in the
upper limb.
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• 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.

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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

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Cathater in right axillary artery
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• Angiogram showing occlusion of
• right ulnar artery, as well as digital occlusion

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• Symptomatic upper extremity arterial occlusive
  disease is uncommon because of the abundant
  collateral network and the infrequency of
  atherosclerosis in the upper extremity

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digital ischemia
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• The patients 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 changeswhite, 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)

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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.
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Brachial segment that demonstrates a high
take-off of the radial artery from the mid
brachial artery.
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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.)
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Distal ulnar artery occlusion and proximal radial
artery occlusion with obliteration of the
superficial palmar arch from distal embolization.
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Digital subtraction angiogram that demonstrates a
normal subclavian axillary brachial segment with
the arm at the patient's side
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Angiogram of upper extremity. The top is in a
normal position. The bottom is in a hyperabducted
position (arrow indicates area of stenosis).
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