Vascular disease in the arm is much less common. One of the causes of circulation problems in the arm is compression of the artery and vein at the root of the arm. This is where the vessels pass over the first rib leaving the chest passing into the axilla (armpit) and onto the arm. The muscles and the clavicle (collar bone) a small space over the rib allowing the vessels to pass to the arm. In some patients this becomes a problem. One of the reasons for this is a congenital extra rib. These patients have an extra rib over which the vessels need to pass into the arm. Sometimes there may not be a full rib, but some cartilage or a fibrous band can be enough to cause a problem with compression of the blood vessels. In these cases the symptoms may present at a relatively young age.

Even when the anatomy is normal, and injury  may lead to changes which caused compression. In some patients change in posture can be a factor with symptoms coming on when aged over 30.

There are also nerves close to the blood vessels and some of the symptoms from this condition are caused by pressure on nerves rather than the blood vessels. A key finding in this condition is that the symptoms are worse in certain positions. Elevating the arms above the head such as when washing,  drying and brushing hair can be uncomfortable with pins and needles, numbness, and the hand turning white. Sometimes the driving position is uncomfortable, and holding a mobile phone to the ear can cause symptoms.

There are other conditions that give similar symptoms. Problems with trapped nerves from the neck, elbow and wrist need to be considered as other possible causes. After an examination of the arm and pulses a series of investigations is often required to confirm the diagnosis. Imaging the vessels with ultrasound or MR I can be helpful. The scan above shows a blocked artery on the right of the picture compared to a more normal artery passing out horizontally to the arm on the left of the picture . This was caused by compression related to an extra congenital rib.

 This angiogram in the same patient shows the arm artery on the right side . following this up and across it comes to a halt. This is where the artery is compressed by the muscles and rib at the "thoracic outlet"

The following xrays of the chest have changes in the ribs. Can you spot the extra ribs and the missing rib at the top of the pictures ?

TREATMENT

Many patients can improve  with some physiotherapy to help  strengthen the muscles around the shoulder and neck  and improved posture.  If the symptoms can be controlled in this way no further  treatment is often required providing  the blood vessels on not being  damaged by compression.  If  despite physiotherapy the symptoms have not  improved then a procedure to  decompress the vessels and nerves  can be performed.  Congenital ribs and bands  can be removed via a procedure  at the base of the neck above the collarbone .  This may be sufficient to free up  the  nerves and vessels relieving the symptoms .  When there are no additional  ribs or bands the normal  first rib may be  causing some of the compression.  This can be removed by an operation through the axilla (armpit)  in order to remove compression.

Care is required with the vessels and nerves during the  these operations.  Vascular surgeons therefore  commonly  perform these procedures.  If the vessels have been damaged by compression there is occasionally the need  to repair  or bypass the arteries  as well as carrying out the decompression.

These operations involve a general anaesthetic. Patients undergoing this surgery may spend  2-3 nights in hospital  depending on the level of discomfort after the procedure .  Full recovery to normal function can take  2-3 months.  Major complications are rare with this surgery.  There may be some temporary weakness of the hand or arm  after the procedure.