Upper Limb CT Angiography in the Emergency Department

A range of abnormalities may acutely affect the upper limb (UL) extremity vasculature including trauma, peripheral vascular disease, and inflammatory conditions. Significant technical advances in computed tomography angiography (CTA) have led to the widespread adoption of this noninvasive modality for rapid evaluation of UL arterial abnormalities in the emergency department setting. A key advantage of CTA over traditional digital subtraction angiography (DSA) is the ability to evaluate concurrent osseous and soft tissue injuries. Accurate identification of pathology requires knowledge of normal UL arterial anatomy in addition to a high-quality study, which may be achieved with a robust CTA protocol. We describe the spectrum of imaging findings on upper limb CTA associated with various acute presentations. Traumatic vascular injuries may occur secondary to penetrating and blunt aetiologies appearing on CTA as contrast extravasation, pooling, pseudoaneurysm, occlusion, and arteriovenous fistula. Peripheral vascular disease manifests as atherosclerotic plaques with thready downstream opacification, and these may precipitate acute thromboembolic events. Inflammatory conditions affecting the UL vasculature includes large and small vessel vasculitides characterised by arterial mural thickening. The use of modalities, including ultrasound and magnetic resonance angiography (MRA), should be considered for further characterisation where appropriate.