Very few patients present with symptoms related to major occlusive arterial disease of the arms but symptoms of claudication and rest pain do occur. Brachial emboli are relatively common and the presentation is nearly always with numbness and weakness rather than a white hand. Management involves local anaesthetic embolectomy followed by long-term anti-coagulation.

Figure 15.14. Intra-arterial thrombolysis.

Raynaud's disease is common in younger patients. Vasospasm causes coldness and pallor in relation to certain stimuli (usually cold) followed by blue then red discoloration and pain as the arterial circulation dilates again. Occasionally, the disease is severe enough to produce digital ulceration or gangrene. The majority of patients can be managed by avoidance of cold stimuli and the use of heated gloves if needed. Nifedipine can give short-term relief but headache often limits its use in the long term. Episodes of ulceration or gangrene may require guanethidine blockade or hospital admission for prostacyclin infusion or trans-thoracic endoscopic sympathectomy.

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