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[Angiographic diagnosis of acral circulatory disorders of the upper extremities]
1Institut für Klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Innenstadt, Pettenkoferstr. 8a, 80336, München, Deutschland. zsuzsanna.deak@med.uni-muenchen.de
Insights
Digital subtraction angiography aids in diagnosing upper extremity ischemic lesions, differentiating causes like vasculitis from atherosclerosis. DSA reveals distinct patterns for conditions such as Raynaud's phenomenon, thromboangiitis obliterans, scleroderma, and panarteritis nodosa.
Area of Science:
- Radiology
- Vascular Medicine
- Rheumatology
Background:
- Acral ischemic lesions are uncommon in upper extremities, unlike lower limbs where atherosclerosis dominates.
- Vasculitis and autoimmune diseases are key contributors to upper limb ischemic lesions.
- Raynaud's phenomenon, often presenting without necrosis, is a common feature of acral circulatory disorders.
Purpose of the Study:
- To highlight the diagnostic utility of digital subtraction angiography (DSA) in evaluating upper extremity acral circulatory disorders.
- To describe characteristic DSA findings associated with various vasculitic and autoimmune conditions affecting the hand.
Main Methods:
- Review of angiographic features in patients with acral ischemic lesions of the hand.
- Correlation of DSA findings with underlying etiologies including atherosclerosis, vasculitis, and autoimmune diseases.
- Analysis of specific patterns indicative of Raynaud's phenomenon, thromboangiitis obliterans, scleroderma, and panarteritis nodosa.
Main Results:
- DSA offers high spatial resolution for detecting subtle morphological changes in acral arteries.
- Atherosclerosis typically presents with irregular vessel wall contours.
- Vasculitis and autoimmune diseases often show smooth vessel walls with potential vasospasm; specific patterns differentiate conditions like thromboangiitis obliterans (corkscrew collaterals) and scleroderma (distal occlusions, symmetric affection).
- Panarteritis nodosa is associated with segmental ectasia, stenosis, and microaneurysms.
Conclusions:
- DSA is a crucial tool for the radiological diagnosis of upper limb acral circulatory disorders.
- Distinct DSA features can help differentiate between various underlying causes, guiding clinical management.
- Understanding these angiographic patterns is essential for accurate diagnosis and treatment of hand ischemia.
Abstract:
Acral ischemic lesions rarely affect the upper extremities. While in the lower limbs atherosclerosis is responsible for the majority of lesions, vasculitis and autoimmune diseases play an important role in the pathogenesis of ischemic lesions of the upper limbs. A considerable number of acral circulatory disorders present with Raynaud's phenomenon and often without associated necrosis. Raynaud's phenomenon is mainly idiopathic but may also be secondary to underlying conditions, such as autoimmune diseases and vasculitis. Because of its high spatial resolution and the often discrete morphological findings digital subtraction angiography (DSA) is still an important diagnostic method in the radiological evaluation of acral circulatory disorders of the hand. Angiographic features of vasculitis are not strictly pathognomonic but certain morphologic DSA findings are very typical and may allow for a radiologic diagnosis. For instance, atherosclerosis results in irregular contours of vessel walls in DSA in contrast to autoimmune diseases and vasculitis, which are usually characterized by smooth vessel walls and optional vasospasm, the latter being especially typical for thromboangiitis obliterans and scleroderma. In thromboangiitis obliterans occlusions of the distal hand arteries, corkscrew collateral vessels and subsequent development of fine collateral networks are typical findings. Abrupt or filiform occlusions of distal finger arteries with sparse collateralization and symmetric affection of both hands are suggestive of scleroderma. Disseminated segmental ectasis and stenosis as well as microaneurysms (63% of all patients) are very common in patients with panarteriitis nodosa.
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