What vascular workup is indicated for an adult with intermittent or persistent tingling in one or both upper extremities that may be vascular in origin?

Vascular Workup of Upper Extremity Tingling

Begin with bilateral blood pressure measurement and comprehensive pulse examination of both upper extremities, including Allen's test when hand perfusion is in question, as recommended by ACC/AHA guidelines for vascular assessment. 1

Initial Clinical Assessment

The vascular physical examination for upper extremity symptoms should include:

• Bilateral blood pressure measurement with notation of any interarm asymmetry (>15-20 mmHg difference suggests subclavian stenosis) 1, 2
• Palpation and grading of brachial, radial, and ulnar pulses bilaterally using the standardized scale: 0=absent, 1=diminished, 2=normal, 3=bounding 1
• Allen's test to assess hand perfusion and patency of radial and ulnar arteries 1
• Auscultation for bruits over the subclavian and axillary arteries 1
• Inspection of the hands and fingers for color changes, temperature asymmetry, trophic skin changes, or evidence of digital ischemia 1

Key Diagnostic Considerations

Important caveat: Upper extremity tingling is far more commonly neurologic than vascular in origin. 3 The differential includes cervical radiculopathy, brachial plexopathy, peripheral nerve compression (carpal tunnel, cubital tunnel), and thoracic outlet syndrome. Vascular causes are relatively uncommon but must be excluded when suggested by clinical findings.

Features Suggesting Vascular Etiology:

• Positional symptoms that worsen with arm elevation or specific positions 4
• Cold sensitivity or color changes (pallor, cyanosis) in the digits 4
• Diminished or absent pulses on examination 1
• Interarm blood pressure difference >15-20 mmHg 2
• History of trauma or repetitive overhead activities 5
• Symptoms with exertion that resolve with rest (upper extremity claudication) 4

Diagnostic Testing Algorithm

If clinical examination suggests vascular pathology:

1. Segmental blood pressure measurements of both upper extremities (brachial, forearm, wrist) to identify level of obstruction 1

2. Duplex ultrasound of the subclavian, axillary, brachial, radial, and ulnar arteries as the first-line imaging modality 1

3. Digital plethysmography if hand or finger ischemia is suspected 1

4. CT angiography or MR angiography for anatomical characterization if duplex ultrasound demonstrates significant stenosis or occlusion and intervention is being considered 6

5. Conventional angiography reserved for cases where endovascular intervention is planned 1

When Vascular Testing is NOT Indicated

Vascular imaging is inappropriate when: 1

• Neurologic examination clearly localizes symptoms to a specific nerve root, plexus, or peripheral nerve distribution 3
• Pulses are normal and symmetric bilaterally with no interarm blood pressure difference 1
• Symptoms follow a dermatomal or peripheral nerve distribution without vascular features 3
• No positional or exertional component to symptoms 4

Common Pitfalls

Do not order vascular studies reflexively for all upper extremity tingling. The vast majority of cases are neurologic, and unnecessary vascular testing delays appropriate diagnosis and treatment. 3 Focus vascular workup on patients with objective findings (pulse asymmetry, blood pressure differences, color changes) or specific risk factors (trauma, repetitive overhead work, atherosclerotic disease elsewhere). 1, 4

Consider thoracic outlet syndrome in young patients with positional symptoms, which may have both neurogenic and vascular components requiring specialized provocative maneuvers and imaging. 4