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ANGIOGRAPHY of the UPPER EXTREMITY Printed in the Netherlands by Koninklijke Drukkerij G.J.Thieme Bv, Nijmegen ANGIOGRAPHY of the UPPER EXTREMITY

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ANGIOGRAPHY of the UPPER EXTREMITY Printed in the Netherlands by Koninklijke Drukkerij G.J.Thieme Bv, Nijmegen ANGIOGRAPHY of the UPPER EXTREMITY 1 f - h-' ^^ ANGIOGRAPHY OF THE UPPER EXTREMITY Printed in The Netherlands by Koninklijke drukkerij G.J.Thieme bv, Nijmegen ANGIOGRAPHY OF THE UPPER EXTREMITY PROEFSCHRIFT ter verkrijging van de graad van Doctor in de Geneeskunde aan de Rijksuniversiteit te Leiden, op gezag van de Rector Magni- ficus Dr. A. A. H. Kassenaar, Hoogleraar in de faculteit der Geneeskunde, volgens besluit van het college van dekanen te verdedigen op donderdag 6 mei 1982 te klokke 15.15 uur DOOR BLAGOJA K. JANEVSKI geborcn 8 februari 1934 te Gradsko, Joegoslavie MARTINUS NIJHOFF PUBLISHERS THE HAGUE - BOSTON - LONDON 1982 PROMOTOR: Prof. Dr. A. E. van Voorthuisen REPERENTEN: Prof. Dr. J. M. F. LandLandsmees r 1 Prof. Dr. J. L. Terpstra ! I Copyright © 1982 by Martinus Nijhoff Publishers, The Hague All rights reserved. No part of this publication may be repro- duced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the pub- lishers, Martinus Nijhoff Publishers,P.O. Box 566,2501 CN The Hague, The Netherlands if ••»• 7b w^ wife Charlotte To Lucienne, Lidia and Dejan h {, ,;T1 ii-"*1 ™ ffiffp"!»3^>»'*!W^iyJiMBiaMMrar^ ACKNOWLEDGEMENTS This thesis was produced in the Department of Radiology, Sirit Annadal Hospital, Maastricht. i Case material: Prof. Dr. H. A. J. Lemmens, surgeon. Technical assistence: Miss J. Crijns, Mrs. A. Rousie-Panis, Miss A. Mordant and Miss H. Nelissen. Secretarial help: Mrs. M. Finders-Velraad and Miss Y. Bessems. Photography: Mr. C. Evers. Graphical illustrations: Mr. C. Voskamp. Correction English text: Dr. Chris Lawrence and Mrs. G. P. Bieger-Smith. Si t * •<* CONTENTS Chapter 1 1 INTRODUCTION 1 1.1 Outline of the Thesis 1 Chapter 2 2 THE HISTORY OF ANGIOGRAPHY OF THE UPPER EXTREMITIES 3 Chapter 3 3 EXAMINATION TECHNIQUE 5 3.1 Preparation of the Patient for Upper Extremity Angiography 5 3.2 Premedication for Angiography under Local Anaesthesia 6 3.3 Instruments, Equipment and Contrast Media 6 3.3.1 Catheters 6 3.3.2 Needles and Guide Wires 6 3.3.3 Equipment 7 3.3.4 Local Anaesthesia 7 3.3.5 Contrast Media 7 3.4 Technique of Catheterization 7 3.4.1 Catheter Flushing 9 3.5 Catheter Technique for Hand Angiography 10 3.5.1 Introduction of the Catheter 10 3.5.2 Roentgenography 13 3.5.3 Postangiographic Care 13 3.6 Another Method for Hand Angiography (Direct Brachial Angiography) 14 3.6.1 Advantages and Disadvantages of This Method 16 3.7 Complications 16 3.7.1 General Complications 16 3.7.2 Angiographic Complications: Our Experience 17 3.7.3 Neurological Complications Related to Catheter Angiography of the Brachiocephalic Veseels 17 3.7.4 Neurological Complications: Our Experience 18 *.''.?^ X CONTENTS Chapter 4 4 VASCULAR TONUS AND PHARMACOANGIOGRAPHY 21 4.1 General Anatomic and Histologic Considerations 21 4.1.1 Innervation of the Vascular System of the Upper Extremities 22 4.2 Physiology of Vascular Tonus: General Discussion 23 4.3 Disturbed Vascular Tonus of the Extremities 24 4.3.1 Clinical Manifestations of Vasospasm of the Extremities 26 4.4 Roentgenographic Manifestations of Arterial Spasm: Our Experience 26 4.5 Pharmacoangiography 29 4.5.1 Vasodilators Used in Peripheral Angiography: Review of Literature 29 4.5.2 The Use of Tolazoline Hydrochloride in Peripheral Brachial Angiography 31 31 4.5.3 Tolazoline Hydrochloride 31 4.5.4 Toxic Effects 31 4.5.5 Contra-Indications 31 4.6 Our Investigations 31 4.6.1 Selection of Proper Drug 32 4.6.2 Time-Dose Relation in the Use of Tolazoline 32 4.6.3 Technique 34 4.6.4 Conclusions Chapter 5 5 EMBRYOLOGY OF THE ARTERIES OF THE UPPER LIMB 37 Chapter 6 6 ANATOMY OF THE ARTERIAL SYSTEM OF THE UPPER EXTREMITIES 41 6.1 Aortic Arch 41 6.1.1 Different Types of Aortic Arch 41 6.2 The Arteries of the Upper Extremities on the Aortograms 47 6.2.1 The Innominate Artery 47 a Dimensions of the Innominate Artery 48 b Branches 48 c Variations 48 6.3 The Arteries of the Upper Extremities on Selective Arteriograms 50 6.3.1 The Subclavian Artery 50 6.3.2 The Vertebral Artery 51 a Calibre of the Vertebral Artery 52 6.3.3 The Internal Mammary Artery 53 a Variations 53 6.3.4 The Thyrocervical Trunk 54 a Variations 54 6.3.5 The Costocervical Trunk 56 a Branches 56 6.3.6 The Axillary Artery 56 a Branches 56 b Variations 57 CONTENTS XI 6.3.7 The Highest Thoracic Artery 59 a Variations 59 6.3.8 The Thoracoacromial Artery 60 6.3.9 The Lateral Thoracic Artery 60 a Variations 60 6.3.10 The Subscapular Artery 61 a Variations 61 6.3.11 The Scapular Circumflex Artery 62 a Variations 62 6.3.12 The Humeral Circumflex Artery 62 a The Posterior Humeral Circumflex A rtery 63 b The Anterior Humeral Circumflex Artery 63 c Variations 64 6.3.13 The Brachial Artery 65 6.3.14 Anastomoses around the Elbow Joint 66 a The Deep Brachial A rtery 66 b The Superior Ulnar Collateral Artery 66 c The Inferior Ulnar Collateral Artery 67 d Variations 67 6.4 The Arteries of the Forearm 69 6.4.1 The Radial Artery 69 a Variations 70 6.4.2 The Ulnar Artery 70 a Branches 71 b Variations 71 6.4.3 The Common Interosseous Artery 71 a Variations 71 6.4.4 Persistent Median Artery 73 6.5 The Arteries of the Hand 73 6.5.1 Introduction 73 6.6 Arterial Patterns in the Hand: Based upon a Study of 500 Arteriograms 77 6.6.1 Materials and Methods 77 6.7 The Deep Volar (Palmar) Arch 79 6.7.1 Complete Arch 79 a Different Types of Complete Deep Volar A rch 79 6.7.2 Incomplete Arch 82 a Different Types of Incomplete Deep Volar arch 85 6.7.3 Other Observations and Discussion 85 6.7.4 The Arteria Princeps Pollicis 85 a Variations 88 \ 6.7.5 The Arteria Radialis Indicis 89 ) a Variations C9 I 6.7.6 The Volar Metacarpal Arteries 89 \ 6.8 The Superficial Volar (Palmar) Arch 91 ,j 6.8.1 Complete Arch 9i i a Different Types of Complete Superficial Volar Arch 91 6.8.2 Incomplete Arch 98 ; a Category I 99 ; b Category II 103 } c Category III 110 ' d Category IV 112 3 XII CONTENTS 6.9 Other Observations and Discussion 114 6.9.1 The Calibre of The Deep and The Superficial Volar Arches 114 6.9.2 Branches of the Superficial Volar Arch 115 6.9.3 The Common Volar Digital Arteries 115 a Variations 115 6.9.4 Tandler's Artery 117 6.9.5 Persistent Median Artery 119 6.9.6 The Proper Volar Digital Arteries 119 6.10 Conclusions 119 6.10.1 Brachial and Antebrachial Arteries 119 6.10.2 Arteries of the Hand 120 Chapter 7 7 VASCULAR INJURIES OF THE UPPER EXTREMITY 123 7.1 Different Types of Injury: Signs and Symptoms 123 7.2 Traumatic Diseases of the Arteries of the Proximal Part of the Upper Extremity 124 7.2.1 Injuries of the Innominate and Subclavian Arteries 124 7.2.2 Injuries of the Axillary Artery 125 7.2.3 Injuries of the Brachial Artery 125 7.2.4 Angiography 126 7.2.5 Report of Our Cases 128 7.3 Traumatic Arterial Injuries of the Forearm and Hand 130 7.3.1 Chronic Arterial Injuries 130 a The Hypothenar Hammer Syndrome 130 b The Thenar Hammer Syndrome 132 7.3.2 Analysis of Our Case Material 134 7.4 Conclusions 136 Chapter 8 8 CONGENITAL VASCULAR LESIONS AND VASCULAR TUMOURS 141 8.1 Congenital Stenosis, Atresia, Hypoplasia and Aplasia 141 8.2 Arteriovenous Communications 141 8.2.1 Arteriovenous Malformations 141 8.2.2 Arteriovenous Fistulae 142 8.2.3 Clinical Features 143 8.2.4 Haemangioma 143 8.2.5 Report of Our Cases 144 8.3 Conclusions 147 Chapter 9 9 THE THORACIC OUTLET COMPRESSION SYNDROME 149 9.1 Introduction 149 9.1.1 Historical Background 150 9.2 Anomalies Predisposing to the Thoracic Outlet Compression Syndrome 151 CONTENTS XIII 9.3 Aetiology of Vascular Changes 153 9.4 Symptomatology 154 9.5 Physical Examination 154 9.6 Roentgenological Examinations for the Thoracic Outlet Compression Syndrome and Radiodiagnosis 156 9.7 Our Investigation 157 9.7.1 Arteriography: Technical Aspects 157 9.7.2 Phlebography: Technical Aspects 160 9.7.3 Angiographic Signs of Compression at Different Points of the Thoracic Outlet and Radiological Diagnosis 161 9.8 Case Material 166 9.9 Non-Pathological Occlusions of the Arteries of the Upper Limb due to Incorrect Tositio- ning of the Extremity 176 9.10 Conclusions 176 Chapter 10 10 ARTERIAL OCCLUSIVE DISEASES OF THE UPPER EXTREMITY 179 10.1 Arteriosclerosis 179 10.1.1 Radiological Diagnosis of Arteriosclerosis 180 10.1.2 Analysis of Our Case Material 181 10.1.3 Conclusions 182 10.2 Steal Phenomena 183 10.2.1 Subclavian Steal 183 a Aetiology 184 b Symptomatology 185 c Clinical Diagnosis 186 d Angiography 186 10.2.2 Bilateral Subclavian Steal Syndrome 187 10.2.3 Innominate Steal Syndrome 188 10.2.4 Analysis of Our Case Material 189 10.2.5 Conclusions 191 10.2.6 Thyrocervical Steal Syndrome 192 10.2.7 Analysis of Our Case Material and Report of a Case 192 194 10.2.8 Conclusions 194 10.3 Vasospastic Disorders 194 10.3.1 Raynaud's Disease 194 10.3.2 Raynaud's Syndrome 195 10.3.3 Differential Diagnosis 195 10.3.4 Angiography 195 10.3.5 Angiographic Findings 196 •45 10.3.6 Conclusions 196 10.4 Arterial Embolism and Thrombosis of the Upper Extremities 196 10.4.1 Literature on Arterial Embolism 198 10.4.2 Clinical Manifestations 198 10.4.3 Angiography 199 10.4.4 Analysis of Our Case Material 202 10.4.5 Literature on Arterial Thrombosis 202 10.4.6 Clinical and Radiological Diagnosis XIV CONTENTS 10.4.7 Radiological Differential Diagnosis Between Embolic and Thrombotic Occlusions 202 10.4.8 Conclusions 202 10.5 Fibromuscular Hyperplasia 203 10.5.1 Clinical Manifestations 204 10.5.2 Angiography 204 10.5.3 Our Case Material 204 10.5.4 Conclusions 205 10.6 Thromboangiitis Obliterans (Buerger's Disease) 205 10.6.1 Clinical Manifestations 205 10.6.2 Angiography 207 10.6.3 Analysis of Our Case Material 207 10.6.4 Differential Diagnosis of Thromboangiitis Obliterans and Arteriosclerosis Obliterans 209 10.6.5 Conclusions 209 10.7 Collagen Diseases 210 10.7.1 Scleroderma 210 a C«i ileal Signs of Scleroderma Progressiva 211 b Angiogr hy 211 c A nalysis of Our Case Material 211 10.7.2 Lupus Erythematosus 212 a Angiographic Signs 213 10.7.3 Rheumatoid Arthritis 213 a Angiography 214 10.7.4 Conclusions on Arteriography in Collagen Diseases of the Hand 214 10.8 Conclusions on Angiography in Acquired Vascular Diseases 214 Summary 221 Samenvatting 223 Curriculum vitae 226 Chapter 1 INTRODUCTION The surgical team of St.
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