Noninvasive evaluation of the upper extremity.

Vascular problems of the arm and hand can be assessed by a number of noninvasive modalities that are chosen on the basis of the history and physical examination. For suspected upper-extremity ischemia, we begin with SLPs and velocity-waveform analysis. The former test will define the extent and approximate location of the disease process, and subjective assessment of the waveform will further determine the degree and location of occlusive disease. When digital ischemia is suspected, the Doppler examination combined with intermittent compression of the radial and ulnar arteries is valuable for defining the variable arterial anatomy of the hand and the patency of the common and proper digital arteries. The extent of distal ischemia can be assessed by digital pressures. Duplex scanning has been found to be of value in determining the source of upper-extremity micro-emboli, in imaging suspected aneurysmal changes, and for evaluating arteriovenous fistulae and bypass grafts. Cold testing is used to confirm the diagnosis of Raynaud's disease after excluding proximal occlusive disease. When symptoms suggest intermittent arterial obstruction, arterial compression at the thoracic outlet is assessed by monitoring the arterial waveform during a series of maneuvers that change the anatomy of the outlet. Although a combination of IPG and venous Doppler examination accurately identifies venous occlusion, we routinely use duplex scanning in this setting. In addition to providing both anatomic and hemodynamic information about the subclavian vein, the jugular vein and the junction of the innominate vein can also be studied. Because of its ability to image in a coronal plane, MRI scanning is another nonivasive study that we have found useful for evaluation of venous anatomy and patency of the subclavian, jugular, and innominate veins. Venous thrombosis, often the first manifestation of subclavian vein compression at the thoracic inlet, is best evaluated using duplex scanning.