CT Angiography of the Upper Extremities: Review of Acute Arterial Entities

Abstract

Historically, evaluation of the upper extremity vasculature was performed using digital subtraction angiography. With the advancement of cross-sectional imaging and submillimeter isotropic data acquisition, CT angiography (CTA) has become an excellent noninvasive diagnostic tool for evaluation of the vasculature of the upper extremities. CTA allows quick evaluation of vessel patency and irregularity and achievement of the anatomic detail needed in preoperative planning. When interpreting CTA of the upper extremities, radiologists must be familiar with the normal vascular anatomy, common vascular anomalies, and pitfalls or artifacts that may mimic or mask abnormality. In this review, the authors provide an overview of the utility of CTA of the upper extremities. Also discussed are CTA techniques and the use of several newer technologies including dual-energy and photon-counting detector CT. The utility of CTA in patients with upper extremity trauma is explored, with a focus on assessing vascular injury. Other vascular abnormalities including infection, acute limb ischemia, and vasculitis are discussed. It is imperative for radiologists to be accustomed to CTA of the upper extremities in diagnosing acute vascular abnormalities and to recognize common pitfalls and mimics of these abnormalities. ^©RSNA, 2025 Supplemental material is available for this article.

Graphical abstract

Figure 1.

Arterial anatomy of the upper extremity. (A) Illustration shows the normal arterial vasculature of the arm. (B) Coronal maximum intensity projection (MIP) CT angiogram of the upper arm shows the normal course of the subclavian (dashed yellow line), axillary (dashed blue line), and brachial (dashed green line) arteries. Note that the subclavian artery becomes the axillary artery at the lateral aspect of the first rib. Numbered arrows indicate the internal mammary artery (1), the thyrocervical trunk (2), the costocervical trunk (3), the superior thoracic artery (4), the thoracoacromial artery (5), and the anterior and posterior circumflex humeral arteries (6). (C) Coronal MIP CT angiogram (top) and axial CT image of the lower arm (bottom) show the normal course of the radial (arrowheads), ulnar (yellow arrow), and interosseous (orange arrow) arteries.

Figure 2.

Arterial anatomy of the wrist and hand. (A) Normal arterial vasculature of the wrist and hand. (B) Coronal MIP CT angiogram of the hand shows the normal vascular arterial anatomy. Numbered arrows show the radial artery (1), the ulnar artery (2), the princeps pollicus artery (3), the common palmar digital arteries (4), and the palmar digital arteries (5). D = deep palmar arch, S = superficial palmar arch.

Figure 3.

High bifurcation of the brachial artery. Coronal MIP CT angiogram through the left arm shows high bifurcation with high origin of the left radial artery (solid arrow) from the brachial artery (arrowhead) much more proximal than the expected location of the radial artery origin in the antecubital fossa. Note the high course of the ulnar artery (dotted arrow). The findings represent the most common arterial variant, high bifurcation of the brachial artery.

Figure 4.

Reducing imaging artifacts with photon-counting detector CT. (A) Coronal 50-keV virtual monoenergetic kiloelectron voltage CT angiogram of the upper left arm shows a ballistic fragment (solid arrow) in the medial soft tissues creating an extensive adjacent streak artifact leading to apparent occlusion (dashed arrow) of the brachial artery, which is irregular and decreased in caliber, compatible with a vasospasm (*). (B) Coronal 80-keV virtual monoenergetic kiloelectron voltage CT angiogram of the upper left arm shows a decreased streak artifact, allowing visualization of the underlying brachial artery lumen (arrowhead) and differentiation of vasospasm from occlusion. Note that the intravascular contrast resolution is decreased as a result of the increased virtual kiloelectron voltage. (C) Coronal 120-keV virtual monoenergetic CT angiogram shows a substantial decrease in streak artifact surrounding the ballistic fragment (arrow), but the intravascular contrast is much decreased, illustrating the necessity in balancing reducing streak artifact with contrast resolution.

Figure 5.

Arterial transection in a 55-year-old man with a gunshot wound to the right upper extremity. (A) Axial CT angiogram shows the bullet track (dashed arrows), with a small hematoma in the upper medial arm and associated soft-tissue stranding and gas, with a bullet fragment. (B) Coronal MIP CT angiogram shows a 9-cm segment of complete nonopacification (dashed line) of the right brachial artery, with distal reconstitution above the level of the elbow, which may represent transection, severe vasospasm, thrombosis, or dissection. No active extravasation is identified. The patient underwent exploratory surgery of the right upper extremity, with findings demonstrating transection of the right brachial artery. The patient was treated with a right brachial artery–to–brachial artery reversed saphenous vein bypass graft.

Figure 6.

Active extravasation in a 30-year-old man with a gunshot wound to the left upper extremity. Axial (A) and coronal (B) MIP CT angiograms show an ill-defined contrast material blush compatible with active extravasation (arrow) arising from the mid left radial artery, with surrounding intramuscular hemorrhage.

Figure 7.

Active extravasation and arterial pseudoaneurysm in a 31-year-old man with a gunshot wound to the right upper extremity. (A, B) Axial arterial phase (A) and coronal MIP (B) CT angiograms show traumatic injury to the right upper extremity, with associated active extravasation (black arrow in B) and a small pseudoaneurysm (white arrow) of the brachial artery. There is short-segment nonopacification of the distal brachial artery consistent with transection (dashed line in B), with distal reconstitution of the right radial and ulnar arteries. (C) Immediate delayed axial CT angiogram shows the brachial artery pseudoaneurysm (solid arrow), with active extravasation posteriorly, communicating with the skin surface along the bullet track (dashed arrows). The patient underwent exploratory surgery of the right upper extremity, with repair of the right brachial artery and interposition greater saphenous vein bypass grafting.

Figure 8.

Arterial vasospasm in a 16-year-old adolescent boy with a gunshot wound to the left upper extremity. Coronal (A) and sequential axial (B–D) MIP CT angiograms show a gunshot wound to the left upper extremity, with associated soft-tissue gas and edema. There is a high bifurcation of the brachial artery and severe narrowing of the left ulnar artery (arrowhead in C), with faint opacification for approximately 5 cm (dashed line in A), with a normal caliber of the vessel both proximally (arrow in B) and distally (arrowhead in D), favored to represent arterial vasospasm. A follow-up arterial duplex US examination (not shown) performed 12 hours later showed the patency of the vessel, without luminal narrowing.

Figure 9.

AVF in an 80-year-old woman with a history of coronary artery disease resulting in multiple percutaneous interventions and prior right brachial artery access who presented with right arm fullness and bruit. (A) Coronal MIP CT angiogram of the right upper extremity demonstrates the right brachial artery (black arrowhead) with early filling of an adjacent right upper extremity vein (white arrowhead). (B) Axial CT angiogram shows the direct connection between the right brachial artery and the brachial vein (arrow) consistent with an AVF. (C) Color Doppler US image acquired subsequently shows a communication between the distal brachial artery and vein.

Figure 10.

Multiple arterial injuries of the right upper extremity arteries in an 18-year-old man after he underwent damage-control surgery for a gunshot injury to the right supraclavicular fossa. Axial CT angiograms acquired during the arterial (A) and immediate delayed (B, C) phases, and coronal MIP CT angiograms (D, E) through the right axillary region show large lobulated extravascular collections of contrast material (*), one of which arises from the right axillary artery (solid arrow in A, B, D, E), which does not change between the arterial and immediate delayed phases, a finding that is compatible with a pseudoaneurysm. The pseudoaneurysm communicates with the right internal jugular vein (dashed arrow in C and E), representing a complex AVF. Distally in the upper extremity, there is irregularity of the right axillary and brachial arteries (arrowheads in D), representing diffuse vasospasm.

Figure 11.

Infectious pseudoaneurysm with short-segment thrombosis in a 74-year-old man with a history of mitral valve replacement complicated by endocarditis who presented with flaccid paralysis of the left upper extremity. Axial CT angiogram of the left upper extremity (A) and coronal MIP CT angiogram (B) show a lobulated extravascular collection of contrast material (solid arrow) with minimal surrounding soft-tissue stranding, consistent with an infectious pseudoaneurysm arising from the distal left axillary artery. Distally, there is abrupt short-segment occlusion of the left axillary-brachial artery junction (dashed arrow in B). Irregularity in the mid to distal brachial artery (arrowheads in B) is compatible with an associated vasospasm, which was likely reactive to an underlying soft-tissue infection.

Figure 12.

Soft-tissue infection with arterial vasospasm and septic thrombophlebitis in a 33-year-old woman with a history of intravenous drug use who presented with septic shock and bacteremia. (A) Coronal arterial MIP CT angiogram shows long-segment irregularity of the left axillary and brachial arteries (dotted line) representing reactive vasospasm from soft-tissue infection. (B, C) Axial (B) and coronal (C) venous phase CT angiograms of the left upper extremity show focal occlusion of the left axillary and brachial veins (arrowheads). Adjacent skin and subcutaneous soft-tissue stranding (*) represents the site of intravenous injection and soft-tissue infection.

Figure 13.

ALI due to thromboembolism in a 79-year-old man with a recent septal and inferior wall myocardial infarction who presented with acute pain and numbness in the right upper extremity. (A) Coronal delayed phase CT angiogram of the right arm shows a focal occlusion in the right brachial artery (arrows) representing an embolism. (B) Coronal MIP CT angiogram at the level of the proximal forearm shows occlusion of the interosseous artery (arrow). Note the high origin of the right radial artery. (C) Axial CT angiogram of the right upper extremity shows hypoattenuation of the interventricular septum (arrows) compatible with a known infarct. The source of the embolism was presumed to be the left ventricle.

Figure 14.

ALI from an infected pseudoaneurysm in a 55-year-old man with a history of pulmonary adenocarcinoma and newly diagnosed mitral valve bacterial endocarditis who presented with 1 day of acute right-hand pain, nail splinter hemorrhages, and digital pallor. (A, B) Coronal (A) and axial (B) MIP CT angiograms show focal outpouching (solid arrow) of the right brachial artery (dashed arrows in A) compatible with an infectious pseudoaneurysm. A subtle nonocclusive filling defect representing a thrombus (arrowhead) was noted in the pseudoaneurysm, which was thought to be the nidus of right digital ischemia. The patient was treated with anticoagulation and antibiotic therapy. (C, D) Digital subtraction angiograms acquired before (C) and after (D) placement of a stent (arrows in D) show a persistent nonocclusive thrombus (arrowhead in C), a pseudoaneurysm (solid arrow in C), and the right brachial artery (dashed arrows in C).

Figure 15.

In-stent neointimal hyperplasia and arterial occlusion in a 57-year-old man with a history of left subclavian artery occlusion secondary to trauma after unsuccessful placement of a left subclavian artery stent by means of a carotid-subclavian bypass graft. Coronal (A) and oblique axial (B) MIP CT angiograms of the left upper extremity show a left subclavian artery stent (solid white arrows), with peripheral nonocclusive filling defects (arrowheads in B), representing neointimal hyperplasia. Distally, the subclavian artery became occluded (yellow arrow in A), and the patient was treated with a carotid-subclavian bypass graft (dashed arrows in A).

Figure 16.

Takayasu arteritis in a 20-year-old woman who presented for evaluation of pain in the left upper extremity and chest. Axial (A) and coronal (B) CT angiograms show soft-tissue thickening and stranding surrounding the proximal aspects of the left common carotid and subclavian arteries (arrowheads in A), consistent with Takayasu arteritis. More distally, there is short-segment abrupt nonopacification (solid arrow in B) with surrounding soft-tissue stranding just distal to the vertebral artery origin (dashed arrow in B). Findings are most compatible with arterial thrombosis related to vasculitis.

Figure 17.

Outrunning the bolus. Coronal arterial phase (A) and immediate delayed phase (B) MIP CT angiograms in a 17-year-old adolescent girl with a shoulder injury from playing basketball and no right-hand paresthesia show gradual nonopacification of the mid to distal right ulnar artery during the arterial phase. Given the gradual nonopacification, outrunning of the bolus was suspected, and the technologist performed immediate delayed phase imaging that shows normal opacification (dashed arrow), confirming the flow artifact.

Figure 18.

Streak artifact. Axial (A) and coronal (B) CT angiograms in a 57-year-old woman with a history of Raynaud phenomenon who presented with pain and tingling in the right upper extremity show a focal linear filling defect in the mid right subclavian artery (solid arrow) extending beyond the vessel wall and into the paravertebral soft tissues (dashed arrow) in a projection from the adjacent cervical fusion hardware. Findings represent metal streak artifact from the spinal instrumentation.

Figure 19.

Metal artifact reduction in a 62-year-old man who underwent CT angiography for planning before revision elbow arthroplasty. (A) Axial CT angiogram of the upper extremity at the level of the elbow, without the use of iterative metal artifact reduction, shows extensive beam hardening artifact and is nondiagnostic. (B) Axial CT angiogram with iterative metal artifact reduction shows markedly reduced beam hardening artifact, with visualization of the brachial artery (arrow). (C, D) Coronal MIP CT angiograms without (C) and with (D) iterative metal artifact reduction show normal vascular anatomy (dashed arrow in D).