Images in Cardiovascular Medicine
Demonstration of Unilateral Absence of the Palmar Arch
Without Collateral Circulation
Brent A. Cambron, MD; Paula Ferrada, MD; Roger Walcott, MD;
Swaminathan Karthik, MD; A. Murat Kaynar, MD
A
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27-year-old surgical resident from South America noticed occasional tingling in her right hand on awakening. She performed a modified Allen test1 on her own hands
and noticed a subtle line of demarcation on the palm of her
right hand accompanied by induction of similar tingling
sensations. The demarcation was not seen on the left hand.
We suspected an incomplete palmar arch, and to better
demonstrate these findings, we wrapped the patient’s right
hand with a latex bandage to exsanguinate the extremity.
Assistants applied pressure to both the radial and ulnar
arteries at the wrist as the latex bandage was removed.
Initially, the ulnar artery pressure was released while we
maintained an occlusive force on the radial artery. The
dramatic visual results of the Allen test can be seen in the
photograph (Figure 1). In addition, the subject complained of
nearly simultaneous tingling and numbness in the ischemic
radial artery distribution after arterial occlusion. The evaluation was then repeated to demonstrate the incomplete arch
pattern with occlusion of the ulnar artery (Figure 2). The
subject had some mild residual discomfort in her hand for the
next 12 hours after the test-provoked ischemia, which subsequently subsided.
The Allen test, first described in 1929, was initially used to
evaluate occlusive disease in the ulnar artery distribution and
is used frequently as a bedside evaluation of collateral
circulation of the hand.1 It is estimated that ⬇50% of the
population may have “incomplete” palmar arches, but we
have no conclusive evidence about the percentage of the
population that will have significant loss of flow through the
superficial palmar arch region with occlusion of the radial
artery.2 Considering that 27.5% of radial catheters cause
abnormal radial artery flow with the potential for thrombosis,
medical staff should be cognizant of the potential for ischemia due to this anatomic variance.3 In patients in whom signs
or symptoms of ischemia are noted, immediate removal of the
intra-arterial catheter is required, and further testing for
adequate blood flow may be indicated. For patients having a
radial artery harvest for coronary artery bypass grafting, a
Doppler evaluation may be considered because of the equivocal nature of the Allen test in some patients who would
ultimately not tolerate radial artery ligation.4,5
Disclosures
None.
References
1. Cable DG, Mullany CJ, Schaff HV. The Allen test. Ann Thorac Surg.
1999;67:876 – 877.
2. Fazan VP, Borges CT, Da Silva JH, Caetano AG, Filho OA. Superficial
Palmar arch: an arterial diameter study. J Anat. 2004;204:307–311.
3. Sfeir R, Khoury S, Khoury GH, Rustum J, Ghabash M. Ischaemia of the
hand after radial artery monitoring. Cardiovasc Surg. 1996;4:456 – 458.
4. Agrifoglio M, Dainese L, Pasotti S, Galanti A, Cannata A, Roberto M,
Parolari A, Biglioli P. Preoperative assessment of the radial artery for
coronary artery bypass grafting: is the clinical Allen test adequate? Ann
Thorac Surg. 2005;79:570 –572.
5. Sajja LR, Mannam G, Sompalli S. Neurologic hand complications after
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From the Department of Anesthesia, Critical Care, and Pain Medicine (B.A.C., S.K., A.M.K.) and Department of Surgery (P.F., R.W.), Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, Mass.
Correspondence to Brent A. Cambron, MD, 330 Brookline Ave, Ste 308, Boston, MA 02215. E-mail [email protected]
(Circulation. 2006;113:e6-e7.)
© 2006 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/CIRCULATIONAHA.105.555326
e6
Cambron et al
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Figure 1. Demonstration of an incomplete palmar arch obtained
with radial artery occlusion during modified Allen test.
Figure 2. Incomplete arch pattern with occlusion of the ulnar
artery is seen again on replication of the modified Allen test.
Unilateral Absence of the Palmar Arch
e7
Demonstration of Unilateral Absence of the Palmar Arch Without Collateral Circulation
Brent A. Cambron, Paula Ferrada, Roger Walcott, Swaminathan Karthik and A. Murat Kaynar
Circulation. 2006;113:e6-e7
doi: 10.1161/CIRCULATIONAHA.105.555326
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