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Vascular and Interventional Radiology • Review

Bozlar et al. CT Angiography of Upper Extremity Arterial System

Vascular and Interventional Radiology Review

CT Angiography of the Upper Extremity Arterial System: Part 1—Anatomy, Technique, and Use in Trauma
CT Angiography of the Upper
Extremity Arterial System:
Part 1—Anatomy, Technique,
and Use in Trauma Patients
Ugur
Bozlar 1,2
Torel
Ogur 1
Patrick T. Norton 1
Minhaj S. Khaja 1
Jaime All 1
Klaus D. Hagspiel 1
OBJECTIVE. In this article, we focus on the arterial anatomy of the upper extremities, the
technical aspects of upper extremity CT angiography (CTA), and CTA use in trauma patients.
CONCLUSION. CTA using modern MDCT scanners has evolved into a highly accu-
rate noninvasive diagnostic tool for the evaluation of patients with abnormalities of the upper
extremity arterial system.
FOCUS ON:

Bozlar U, Ogur T, Norton PT, et al.

Keywords: arteries, CT angiography, trauma, upper extremity

DOI:10.2214/AJR.13.11207

Received May 9, 2013; accepted without revision May 10, 2013.

1 Department of Radiology and Medical Imaging, PO Box 800170, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22908. Address correspondence to K. D. Hagspiel (kdh2n@virginia.edu).

2 Department of Radiology, Gulhane Military Medical Academy, Ankara, Turkey.

AJR 2013; 201:745–752

0361–803X/13/2014–745

© American Roentgen Ray Society

AJR:201, October 2013

U
U

pper extremity arterial abnormal- ities are encountered less often than those affecting the lower ex- tremity vasculature. Imaging of

the upper extremity arterial system is gener- ally performed in trauma patients, patients with ischemic symptoms of the upper ex- tremities, for preoperative planning of com- plex upper extremity vascular reconstruc- tions and dialysis access, and for follow-up evaluation of endovascular or surgical proce- dures [1]. Traditionally, imaging of vascular arterial abnormalities of the upper extremity has been the domain of digital subtraction an- giography (DSA) because of its dynamic na- ture and superior spatial resolution [2, 3]. However, DSA is a costly and time-consum- ing invasive procedure that provides limited information about soft-tissue and anatomic relationships and has potential complications. With recent advances in MDCT allowing routine acquisition of submillimeter isotropic datasets, CT angiography (CTA) has become a noninvasive alternative to DSA. Combined with standard postprocessing techniques, CTA has made rapid, accurate noninvasive evaluation of the upper extremity arterial vasculature possible. This article focuses on the role of CTA in the evaluation of arterial abnormalities of the upper extremity.

Normal and Variant Anatomy The upper extremity vascular tree begins at the aortic arch and extends through to the digital arteries (Fig. 1). The subclavian arter- ies originate from the brachiocephalic (innom- inate) artery on the right and directly from the

aortic arch on the left and then run posterior to the subclavian vein. The subclavian artery gives rise to five main branches: vertebral ar- tery, internal thoracic artery (internal mam- mary artery), thyrocervical trunk, costocer- vical trunk, and dorsal scapular artery. The subclavian artery continues as the axillary artery after crossing the lateral margin of the first rib. Its major branches include the supe- rior thoracic, thoracoacromial, lateral thoracic, subscapular, and anterior and posterior humer- al circumflex arteries. These branches supply muscles of the shoulder girdle, humerus, scap- ula, and chest wall. After coursing beyond the inferior lateral margin of the teres major mus- cle, the axillary artery becomes the brachial artery. The brachial artery courses along the medial aspect of the upper arm and gives rise to the deep brachial artery and smaller arteries around the elbow joint. Anteriorly in the ante- cubital fossa, the brachial artery divides into the radial and ulnar arteries. The radial recur- rent artery and the posterior and anterior ulnar recurrent arteries arise immediately beyond the origins of their respective arteries to form anastomoses with branches of the brachial and deep brachial arteries. The radial artery cours- es along the radial side of the forearm to the wrist, traverses the snuffbox, and turns medi- ally to give rise to the deep palmar arch. The ulnar artery arises from the common interos- seous artery and descends on the ulnar side of the forearm to continue into the superficial pal- mar arch. The interosseous artery divides into anterior and posterior branches. There are four arch systems in the hand that have complex anatomic variations. Two

745

Note—VCT and Discovery 750 HD scanners manufactured by GE Healthcare. Definition Flash and Dual-Energy Flash scanners manufactured by Siemens Healthcare. ASIR = adaptive statistical iterative reconstruction (GE Healthcare), SAFIRE = sinogram-affirmed iterative reconstruction (Siemens Healthcare).

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TABLE 1: Scanner-Specific Protocols for Upper Extremity CT Angiography

746

 

Reconstruction

   

Bozlar et

 

Iterative

Mode

 

ASIR 40%

ASIR 40%

ASIR 40%

ASIR 40%

SAFIRE 3

SAFIRE 3

SAFIRE 3

 

Flow

Rate

(mL/s)

 

5

5

4 2.5

42.5

 

Saline

Flush

(mL)

 

40

40

40

40

Contrast

Media

Amount

(mL)

 

100

100

100

100

Noise Index (GE) or Reference Tube Current-Time Product (mAs) (Siemens)

 

29

29

29

29

150

150

150

 

Kilovoltage

 

120

100

120

100

120

100

140/100

 

Scanning FOV

 

Large body

Medium body

Large body

Medium body

50 cm

50 cm

50 cm

 

Reconstruction

Interval (mm)

 

0.625

0.625

0.625

0.625

0.5

0.5

0.45

 

Pitch

 

0.984

0.984

0.984

0.984

1

1

0.9

 

Collimation

Thickness

(mm)

 

0.625

0.625

0.625

0.625

0.5

0.5

0.5

 

Detector

Coverage

(mm)

 

64 × 40

64 × 40

64 × 40

64 × 40

64 × 0.6

128 × 0.6

64 × 0.6

 

Rotation

Time (s)

 

0.5

0.5

0.5

0.5

0.5

0.5

0.33

 

Scanning

Type

 

Helical

Helical

Helical

Helical

Helical

Helical

Helical

 

Scanning Range

 

Carina to just below elbow

Just above elbow through fingertips

Carina to just below elbow

Just above elbow through fingertips

Carina to just below elbow

Just above elbow through fingertips

Carina to fingertips

 

Scanner

VCT

Group 1

Group 2

Discovery 750 HD

Group 1

Group 2

Definition Flash

Group 1

Group 2

Dual-Energy Flash

Group 1

al.

of them are in the palm; the others are in the carpus. The carpal arch system has volar and dorsal components. The dorsal and volar carpal arches are anastomoses of the radial artery and of the ulnar artery dorsal and vo- lar branches, respectively. They also anastomose with the anterior and the posterior interosseous arteries. The dorsal carpal arch arises from three dorsal metacarpal arteries. The superficial palmar arch is formed predomi- nantly by the ulnar artery, with a contribution from the superficial palmar branch of the radial artery. It anasto- moses with the princeps pollicis artery, the radialis indi- cis artery, and the median artery. The deep palmar arch is formed by the anastomosis of the terminal part of the radial artery with the deep palmar branch of the ulnar ar- tery. The superficial palmar arch supplies three common palmar digital arteries, and the deep arch supplies three metacarpal arteries. These branches anastomose in the interosseous space then divide into proper palmar digital arteries. However, the thumb and radial side of the sec- ond finger are supplied directly from the deep palmar arch, whereas the ulnar side of the fifth finger is supplied directly by a proper digital artery from the superficial palmar arch [3]. Communication between the dorsal and palmar systems also occurs by the proximal and distal perforating arteries at the level of the joints and at the fingertip vascular tufts. A high origin of the radial artery from the axillary (2.7–5.0%) or upper brachial artery (5.9–12.1%) is an important variant [4]. A high origin of the ulnar ar- tery is much less common (0.17–2.0%) [5]. Duplica- tions of the brachial artery and hypoplasia or aplasia of the radial and ulnar arteries are rare variants. A persis- tent median artery results from lack of regression of the embryonic median branch arising from the common in- terosseous artery [6]. It is found in about 2–4% of the population. This vessel may supply a palmar arch. Fig- ure 1 illustrates the normal arterial anatomy of the up- per extremity and hand. The rare case of the princeps pollicis artery originating from the interosseous artery is shown in Figure 2.

Acquisition and Postprocessing Techniques Generally, patients are scanned in the supine position with the extremity of interest over the head with the palm ventral and fingers extended and straightened. When pa- tients are not able to extend the arm above the head, which is often the case in posttraumatic conditions, they are im- aged with the arms at the side and positioned in the iso- center as much as possible. Some patients tolerate imag- ing in the prone position better than supine. Metal objects, such as rings and chains, are removed before scanning if possible. Pillows, foam wedges, and tape can be used to immobilize the upper extremity and fingers as much as possible. Occasionally patients have contractions and the fingers cannot be straightened (Fig. 3A). IV access is ob- tained with an 18- or 20-gauge catheter in the antecubi- tal fossa of the contralateral arm. Central lines should be used when bilateral upper extremity imaging is required.

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CT Angiography of Upper Extremity Arterial System

For a complete upper extremity runoff assess- ment, images are acquired in a caudal-cranial direction from the inferior aspect of the aortic

arch to the tips of the fingers (z-axis coverage

is between 500 and 1000 mm), with the cen-

ter of the FOV weighted toward the extremity

of interest. Depending on the clinical situation,

a more targeted study with limited scanning

range can be performed. If evaluation of the arteries of the hand is the objective, keeping the hand warm, by wrapping it in heated blan- kets, for example, is mandatory. Functional evaluation for assessment of thoracic outlet syndrome requires initial scanning in a symptomatic position simulat- ing the Adson maneuver (arm abduction and

extension while rotating the head to the ip- silateral side with extended neck after deep inspiration) [7]. If positive, this can be fol- lowed by scanning in the neutral position (arms adducted and at the side), which is purely limited to the thoracic outlet. Upper extremity CTA can be performed on all MDCT scanners, although we currently perform it only on 64- and 128-MDCT dual- source scanners at our institution. We divide the study in two parts, which are performed sequentially at two different energy levels; the proximal (aortic arch to elbow) portion is scanned at 120 (or depending on patient’s size 100) kV, and the distal portion (elbow to fin- gertips) at 100 or 80 kV. This technique re- sults in increased contrast resolution in the distal extremity (above the level of the skull) where penetration is not an issue. It also pro- longs the overall scanning time by 4–5 sec- onds, which prevents outrunning the contrast bolus on 64-MDCT and higher scanners. Ad- ditionally, the FOV is decreased in the distal region to increase in-plane spatial resolution. To minimize radiation dose, we routinely use iterative reconstruction for all our CTA exam- inations. Arterial scanning delay is determined by automated bolus tracking with the region of interest on the aortic arch. Iodinated con- trast media (we routinely use agents with 350 mg I/mL) is injected at a rate of 4–5 mL/s fol- lowed by a 40-mL saline flush at the same rate. The latter reduces perivenous streak artifacts. The amount of contrast agent we inject rough-

ly corresponds with the length of the scanning

duration. Imaging protocols that are current-

ly used at our institution for 16-, 64-, and 128

MDCT dual-source CT scanners are shown in Table 1. An extensive listing of scanning and contrast injection parameters covering multi-

ple vendors and scanner generations was pub- lished by Leiner et al. [3].

We start the examination by obtaining a bi- plane scout topogram to prescribe the scanning range and FOV. We do not routinely perform unenhanced imaging. We then perform the bo- lus-tracking acquisition followed by the CTA. In patients in whom the scanning outruns the bolus or in patients with suspected slow flow, we routinely perform the distal CTA station study (elbow to fingertips) twice [3].

Postprocessing Like lower extremity CTA examinations, upper extremity CTA examinations produce very large datasets, often exceeding 2000 images. Because the accuracy of upper ex- tremity CTA relies on the creation of volu- metric datasets with submillimeter isotropic voxels, we only use scanners of 64-MDCT or higher for this examination. The large num- ber of images requires the use of advanced image postprocessing techniques to facilitate and speed up interpretation, increase accu- racy, and allow the radiologist to better show the anatomic relationships between vascular lesions and neighboring anatomy to refer- ring physicians. Commonly used techniques are maximum intensity projection (MIP) and volume rendering for creation of an over- view of the vasculature and to localize areas of disease for focused investigation of abnor- malities. This is achieved with multiplanar reconstruction (MPR) and curved planar reconstruction (CPR), which allow assess- ment of the vascular lumen. It is important to stress that any analysis always requires re- view of the axial source images to confirm findings on the reconstructions and to rule out presence of artifacts simulating disease. MPR allows thin-slice viewing of the volu- metric datasets in any plane of orientation re- gardless of the plane of acquisition. CPR is a thin-slice technique that builds on the MPR technique, but instead of providing a recon- struction along a flat plane, it creates a recon- struction along a path. Thus, it can be used to display the entire length of a vessel in one im- age, which is useful for highly calcified ves- sels as well as for grading the severity of a stenosis [3]. MIP algorithms reduce a 3D da- taset to a 2D projection image, with each pixel density equal to the maximum voxel density along the viewing direction. This provides a rapid overview of the vessel of interest but can be of limited use in evaluating vessels that are in proximity to bones, vessels that are heav- ily calcified, or stents. For improved visuali- zation of abnormalities on MIP images, bone removal is helpful. This is usually achieved

using voxel growing techniques or, more re- cently, dual-energy techniques. The latter also permit calcified plaque removal, allowing the display of a pure iodine image [8, 9] (Figs. 3B and 3C). Volume rendering is a perspec- tive rendering technique that provides visual- ization of 3D relationships between structures with varying densities. Volume rendering is extremely useful for presenting data to refer- ring physicians for preprocedure planning [2, 10] (Fig. 3B). To facilitate review of the non- vascular findings on upper extremity CTA, 5-mm-thick axial reconstructions in addition to the thin sections can be obtained.

Artifacts and Pitfalls As with any imaging technique, optimized upper extremity CTA can only be successfully performed when paying close attention to de- tails during the setup of the examination. Pa- tients should be instructed about the impor- tance of not moving during the acquisition and breath-holding, when appropriate. Because motion artifacts can lead to a nondiagnostic ex- amination, the extremity of interest should be immobilized if patients are unable to lie mo- tionless. Taking a little extra time to find a comfortable position for the patient can result in substantial improvements in image quality. Contrast medium administration is one of the most important factors for achieving good image quality. Homogeneous arterial enhancement (without venous contamina- tion) is the goal of CTA. Factors affecting enhancement include patient size, injection rate, contrast medium concentration, table speed, arterial timing technique, and cardi- ac output. It should be noted that these fac- tors are interdependent and should be consid- ered when modifying parameters. In general, patients who are larger require higher iodine flux, which can be achieved by increasing the flow rate or the contrast medium concentra- tion. Table speed (and thus pitch) determines the rate of acquisition. If the table speed is faster than the rate contrast medium travels thought the arteries, the bolus will be outrun, resulting in inadequately opacified vessels. This is especially applicable to 64-MDCT scanners with large z-direction detector cov- erage. Because of the wide variety of patients encountered for upper extremity CTA, either bolus timing or bolus tracking should be used for accurate timing of the contrast bolus. Pa- tients with low cardiac output will require longer scanning delays, and patients with high cardiac output may require increased in- jection rates to keep the contrast bolus tight.

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Bozlar et al.

Radiation dose will have a significant im- pact on image quality. Although less radia- tion exposure is needed for the distal upper extremity, the more central region of imaging requires a higher dose, especially in obese pa- tients. Image noise can be a problem in this patient group. Iterative reconstruction algo- rithms help overcome this problem in most

rapidly at the time of initial trauma imaging and provides a road map for subsequent inter- ventions. Unlike DSA, CTA provides excel- lent osseous and soft-tissue detail in addition to vascular information, which significantly facilitates diagnosis in trauma victims [15]. Arterial injuries of the upper extremities oc- cur in the setting of both blunt and penetrating trauma. Posttraumatic vascular abnormalities include spasm, external compression, dissec- tion (Fig. 5), occlusion or transection (Fig. 6), arteriovenous fistula (AVF) development (Fig. 7), pseudoaneurysm formation, rupture, and transection. Multiphasic examinations can be performed if necessary to further assist in the diagnosis of extravasation, pseudoaneurysm formation, or AVF. Spasm and external vascu- lar compression may be identified as smooth narrowing of the vessel lumen. In difficult cas- es, pseudoaneurysms can easily be differenti- ated from extravasation if late phase imaging is performed. Pseudoaneurysms maintain their shape and follow opacification characteristics of the aorta, whereas in arterial extravasation, contrast material spreads along tissue planes and has increased attenuation compared with parent arteries on delayed images [13, 16]. A linear hypodensity within the vessel lumen may be seen in dissection with or without dis- tal vessel occlusion. AVFs may be seen after trauma to both arteries and veins and can be identified by early venous opacification [13, 16]. Dissection or occlusion of the brachial artery occasionally complicates endovascular procedures performed from that access vessel. Several authors have described their expe- rience with and the efficacy of CTA in initial and delayed diagnosis of vascular trauma of the extremities in general; however, only lim- ited data are available specifically concen- trating on the upper extremity [17–21]. Us- ing helical CTA, Soto et al. [20] showed high sensitivity (95.1%) and specificity (98.7%) for detection of traumatic arterial injuries, including partial and complete occlusion, pseudoaneurysm formation, and presence of AVFs and intimal flaps. In a recent prospec- tive study by Inaba et al. [18], 38.3% of 635 patients undergoing CTA for suspected vas- cular trauma of the extremities had the up- per extremity imaged. The authors report- ed 100% sensitivity and specificity of CTA in the diagnosis of upper extremity vascular trauma in the absence of artifact. Regarding artifacts, White and colleagues [19] found that CTA detected 94% of traumatic vascu- lar injuries when faced with metallic artifacts from penetrating trauma. The authors con-

cluded that CTA is promising in the evalua- tion of traumatic vascular injury and may be an alternative to DSA, similar to the findings reported by Anderson and colleagues [17]. In addition, the recent developments in dual-en- ergy CT and spectral CT may mitigate some artifacts [8, 17].

cases [11]. Although arterial wall calcification

Conclusion CTA is an important diagnostic imaging modality for the evaluation of upper extremi- ty arterial abnormalities. High-quality CTA of the upper extremities is feasible on modern CT scanners using optimized scanning and con- trast injection technique. Its 24-hour availabil- ity, rapid acquisition, minimal invasiveness, and display of both vascular and musculoskel- etal structures makes it particularly attrac- tive for the evaluation of patients with blunt or penetrating trauma to the upper extremity.

Acknowledgment We gratefully acknowledge the contribu- tion to this work by Lauren M. Hagspiel of the College of Arts and Sciences at the University of Virginia.

is

not as common in the upper extremity as it

is

in the lower extremity, it can be problematic

when present. Calcifications bloom when stan- dard window level settings are used, leading to an overestimation in the degree of stenosis. Vascular stents also can cause a similar prob- lem. To limit these effects, wide bone window level settings (for example, width, 2000 HU; level, 500 HU) should be used for evaluation. Generally, a smooth kernel is used in recon- struction of CTA images, allowing an accu- rate depiction of the diameter of the vessels while also suitable for postprocessing. A sharp kernel should also be used for reconstruction when stents or severe vessel wall calcifications are present; it will minimize the blooming ef- fect but will increase image noise, which can be reduced by the use of iterative reconstruc- tion [12]. More recently, dual-energy bone and plaque removal techniques have shown prom- ise in the evaluation of the lower extremity ar- terial system [8, 9]. Our preliminary experi- ence with this technique has been favorable when assessing the arteries to the level of the wrist (Fig. 3). Some more frequently encoun- tered artifacts are shown in Figure 4.

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high suspicion of arterial injury that would warrant DSA because it can be performed

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CT Angiography of Upper Extremity Arterial System

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12. Funama Y, Oda S, Utsunomiya D, et al. Coronary artery stent evaluation by combining iterative re- construction and high-resolution kernel at coro- nary CT angiography. Acad Radiol 2012;

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tion with 64-section whole-body CT angiography. RadioGraphics 2012; 32:609–631

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Fig. 1—Drawing shows normal arterial anatomy of

upper extremity and hand. 1 = brachiocephalic artery,

2

= subclavian artery, 3 = common carotid artery,

4

= vertebral artery, 5 = thyrocervical trunk, 6 =

costocervical trunk, 7 = internal thoracic (mammary)

artery, 8 = pectoral branch, thoracoacromial artery,

9 = acromial branch, thoracoacromial artery, 10 =

lateral thoracic artery, 11 = subscapular artery, 12 =

circumflex scapular artery, 13 = axillary artery, 14 = brachial artery, 15 = anterior branch, circumflex humeral artery, 16 = posterior branch, circumflex humeral artery, 17 = profunda brachial artery, 18 = radial recurrent artery, 19 = ulnar recurrent artery,

20

= superior ulnar collateral artery, 21 = radial artery,

22

= ulnar artery, 23 = interosseous artery, 24 =

deep palmar arch, 25 = superficial palmar arch, 26 = princeps pollicis artery, 27 = metacarpal arteries,

28 = common palmar digital artery, 29 = proper digital

artery, 30 = radialis indexes, 31 = proper palmar digital

artery.

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Copyright ARRS. For personal use only; all rights reserved A Bozlar et al. B Fig. 2—

A

Bozlar et al.

For personal use only; all rights reserved A Bozlar et al. B Fig. 2— Normal variant

B

Fig. 2—Normal variant in 46-year-old woman. A and B, CT angiography (A) and digital subtraction angiography (B) images show abnormal origin of princeps pollicis artery (asterisk , B) from interosseus artery (arrowhead , B).

, B ) from interosseus artery ( arrowhead , B ). A B C Fig. 3—

A

, B ) from interosseus artery ( arrowhead , B ). A B C Fig. 3—

B

, B ) from interosseus artery ( arrowhead , B ). A B C Fig. 3—

C

Fig. 3—Dual-energy upper extremity CT angiography in 57-year-old woman. A, Volume-rendered image shows positioning of arm in patient with pulseless left upper extremity and contractures necessitating use of restraints (arrow ). B, Volume-rendered image after dual-energy bone removal shows atherosclerotic occlusion of subclavian and diffuse disease of axillary artery (arrowheads ). Left internal carotid artery had high-grade stenosis (arrow ). C, Maximum-intensity-projection image after dual-energy bone removal of forearm and hand shows only ulnar artery to be patent (arrowheads ).

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CT Angiography of Upper Extremity Arterial System

reserved CT Angiography of Upper Extremity Arterial System A B Fig. 4— Metal fragments causing streak

A

reserved CT Angiography of Upper Extremity Arterial System A B Fig. 4— Metal fragments causing streak

B

Fig. 4—Metal fragments causing streak artifact due to beam hardening in 62-year-old man. A, In this example, CT image shows metal shot causing star pattern due to focal high density. Streak artifacts can lead to appearance of stenosis or occlusions, resulting in false-positive findings. B, CT image shows venous contamination can make assessment of arteries difficult.

contamination can make assessment of arteries difficult. A B Fig. 5— Gunshot injury with focal axillary

A

contamination can make assessment of arteries difficult. A B Fig. 5— Gunshot injury with focal axillary

B

Fig. 5—Gunshot injury with focal axillary artery dissection in 26-year-old man who presented to emergency department with gunshot wound to left chest, decreased sensation in his left arm, and decreased movement in his hand. A, Maximum-intensity-projection image shows focal intimal injury to left axillary artery (arrowhead) with adjacent soft-tissue injury and hematoma (asterisk ). B, Volume-rendered image illustrates proximity of bullet path (arrowhead) to vascular injury.

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Bozlar et al.

For personal use only; all rights reserved Bozlar et al. Fig. 6— 10-year-old boy who presented

Fig. 6—10-year-old boy who presented with near- complete amputation of right upper extremity, pulselessness and numbness in extremity, and inability to move his fingers after all-terrain vehicle accident. Volume-rendered image shows long-segment occlusion of brachial artery with reconstitution of ulnar artery distally (arrowheads ) as well as relationship of vascular injury to displaced humerus fracture.

of vascular injury to displaced humerus fracture. A B Fig. 7— 34-year-old man with history of

A

of vascular injury to displaced humerus fracture. A B Fig. 7— 34-year-old man with history of

B

Fig. 7—34-year-old man with history of gunshot wound to right upper extremity and subsequent development of arteriovenous fistula (AVF). A, Volume-rendered image shows simultaneous enhancement of arteries and veins of proximal upper extremity due to high-flow AVF (arrowheads ). Note metal artifact from bullet fragments (asterisk ). B, Multiplanar reformation image shows incidental finding of severe compression of subclavian artery at thoracic outlet (arrow ).

FOR

YOUR

INFORMATION

The reader’s attention is directed to part 2 accompanying this article, titled “CT Angiography of the Upper Extremity Arterial System: Part 2—Clinical Applications Beyond Trauma Patients,” which begins on page 753.

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AJR:201, October 2013