Anatomical Distribution Patterns of Peripheral Arterial Disease in the Upper Extremities According to Patient Characteristics: A Retrospective Cohort Study

Abstract

Purpose: Peripheral arterial disease (PAD) greatly affects the patients' quality of life. We aimed to investigate the affected anatomical sites and distribution patterns in upper extremity PAD using computed tomography angiography (CTA). Furthermore, we sought to identify the correlations between patient characteristics and the identified patterns.

Patients and methods: This was a retrospective chart review of upper limb CTA findings from patients with symptomatic PAD aged >18 years. Significant variables from univariate logistic regression analysis were further tested using multivariate logistic regression analysis. Statistical significance was set at p < 0.05, with confidence intervals of 95%.

Results: The mean age of the 102 included patients with upper extremity PAD was 55.45 years. Laterality analysis revealed that the upper left limb segments were more affected than the upper right limb segments (42 vs 63; left-to-right ratio, 3:2). The forearm was the segment most affected by stenotic PAD (62 segments, 3.37%). The arm was the segment most affected by occlusive PAD (14 segments, 0.76%). Diabetes mellitus (DM) and hypertension (HTN) were significant predictors of PAD (p = 0.046). In patients with DM, the occlusive form of PAD was dominant in the arm (18.18%); however, the stenotic form prevailed in the forearm (72.72%). In patients with HTN, the occlusive form of PAD was predominant in the arm (45.45%); however, the stenotic form tended to occur in the arm and forearm (90.90%).

Conclusion: The distribution patterns of upper extremity PAD are linked to its underlying pathophysiology. HTN and DM are the most frequent comorbidities in patients with upper extremity PAD. Angiographically, PAD in these patients is likely to present as stenosis rather than as occlusion. This is vital for interventionists who deviate from radial arterial access in patients with PAD. Therefore, targeted screening standards are required, and further studies on PAD are warranted.

Keywords: angiography; computed tomography; diabetes mellitus; hypertension; stenosis.

Figure 1

Patient selection flowchart displays the included and excluded cases as well as the final sample size.

Figure 2

Prevalence and severity of chronic kidney disease (a) and obesity (b) in patients with upper extremity peripheral arterial disease.

Figure 3

Radiological image from a 47-year-old man with type 2 diabetes mellitus and upper extremity peripheral arterial disease. Three-dimensional, reformatted, volume-rendered computed tomography angiography image shows the high origin of the brachioradial branch (arrow), which represents a higher bifurcation point of the brachial artery. The atherosclerotic and multifocal atherosclerotic segments (arrowheads), leading to attenuated hypoperfusion of the palmar arcs (asterisks), are observed.

Figure 4

Radiological images from a 45-year-old man with hypertension and upper extremity peripheral arterial disease. The patient reported that the right upper limb felt cold and pained for a week prior to presentation. Upon examination, the radial pulse was absent. (a) A three-dimensional, reformatted, volume-rendered computed tomography angiography (CTA) image acquired from the same patient, with the left arm abducted and externally rotated, shows atherosclerotic changes (arrowheads) with an abrupt cut in the distal part of the brachial artery just before the antecubital fossa (arrow). (b and c) Catheter-directed angiogram confirms the CTA findings of an occluded brachial artery (arrowheads). (d) Further characterization of the distal reconstitution of the radial artery by small collaterals. (e) The thrombus is crossed successfully. (f) The interventionalist used catheter-directed thrombolysis to lyse the thrombus and prevent a distal embolic shower through endovascular manipulation. (g) Final angiographic examination reveals restored flow in the upper right extremities; the patient’s symptoms resolved subsequently. However, a partial filling defect (indicating residual thrombosis) is seen to have persisted in the brachial artery (arrow); this required a more conservative management.