Reproducibility of the SPI-US protocol for ultrasound diameter measurements of the Posterior Circumflex Humeral Artery and Deep Brachial Artery: an inter-rater reliability study

The deep brachial artery - a meta-analysis of its origin and diameter with a review of the literature

The deep brachial artery (DBA) is the first and largest branch of the brachial artery. Multiple variations of the DBA's origin, termination, and diameter have been reported in the literature. Major online medical databases such as PubMed, Scopus, Embase, Web Of Science, and Google Scholar were searched in order to find all studies considering origin variations and the diameter of the DBA. The prevalence of the DBA originating directly from the axillary or brachial artery was shown to be 92.87%. DBA originating indirectly from the axillary or brachial artery, as a common trunk with other arteries, was found to be 7.13%. The mean diameter of the DBA was shown to be 2.05 mm. The authors of the present study believe that this is the most accurate and up-to-date meta-analysis considering origin patterns and the diameter of the DBA. Additionally, this study contains a comprehensive literature review in which current detailed anatomical knowledge concerning the DBA was gathered. The results of this study could provide a helpful tool for physicians, especially surgeons, dealing with an upper limb in their daily practice. This article is protected by copyright. All rights reserved.

A systematic review on posterior circumflex humeral artery pathology: sports and professions at risk and associated risk factors

INTRODUCTION

Posterior circumflex humeral artery (PCHA) aneurysm formation and thrombosis as overuse injury in the dominant shoulder can result in ischemia of the forearm, hand and digits due to arterial embolisms. Increased awareness among physicians is necessary as PCHA pathology (PCHAP) might be underdiagnosed. Knowledge of sports and professions at risk and risk-factors for obtaining PCHAP is essential for the development of future preventive measures. This study aims to identify sports and professions at risk as well as risk factors for PCHAP.

EVIDENCE ACQUISITION

The databases of MEDLINE, EMBASE, BIOSIS, CINAHL and SPORTDiscus were systematically searched.

EVIDENCE SYNTHESIS

Twenty-seven papers fulfilled the inclusion criteria and described 67 patients with PCHAP involved in seven sports and three professions. The sports (number of cases) were volleyball (41), baseball (13), swimming (1), tennis (3), American football (2), canoeing (1) and yoga (1) (2 unknown). The professions included a baseball coach, a circus trapeze artist and a mechanic. Apart from expert opinions, no studies have identified risk factors for PCHAP. An anatomic variation of the PCHA origin is suggested to be protective for PCHAP.

CONCLUSIONS

PCHAP is reported in seven overhead sports and three professions. No risk factors for PCHAP were identified. An anatomic variant of the PCHA origin was found to be a potential protective factor for PCHAP. Physicians should be cautious for distal embolization as a result of PCHAP in athletes and workers, both adult and adolescent, involved in repetitive powerful overhead movements.

Posterior circumflex humeral artery pathology and digital ischemia in elite volleyball: Symptoms, risk factors & suggestions for clinical management

OBJECTIVES

To assess the association between posterior circumflex humeral artery (PCHA) pathology (PCHAP), symptoms and associated risk factors, in elite volleyball players, and to suggest profiles for clinical management and monitoring.

DESIGN

Cross-sectional study.

METHODS

A questionnaire assessed symptoms of digital ischemia (DI) in the dominant hand and risk factors among 278 elite indoor and beach volleyball players of whom 6.1% (17/278) was diagnosed with PCHAP using ultrasound. Odds Ratios (OR) including 95% confidence intervals (95%CI) were calculated using binary logistic regression.

RESULTS

All 278 players completed the questionnaire. Three participants with PCHAP were symptomatic (18%). Ninety-three of 96 symptomatic participants had no PCHAP (OR=0.39; 95% CI 0.13-1.13). Total years playing volleyball (OR 1.14; 95% CI 1.03-1.25) and age (OR 1.17; 95% CI 1.00-1.29) were dose-response related risk factors: a volleyball career of ≥17 years and age of ≥27 years were associated with a 9-fold and 14-fold increased risk of PCHAP, respectively.

CONCLUSIONS

The volleyball career duration and age are dose-response related risk factors for PCHAP among elite indoor and beach volleyball players. DI symptoms are prevalent in a minority of athletes with PCHAP (3/17; 18%). To enable worldwide standardized care for these athletes at risk, four profiles for clinical management and monitoring have been suggested based on questionnaire and ultrasound outcomes.

Diagnostic properties of the SPIQuestionnaire to detect Posterior Circumflex Humeral Artery Disease in elite volleyball players: a cross-sectional study

OBJECTIVES

Sports related aneurysmal degeneration and thrombosis of the Posterior Circumflex Humeral Artery (PCHA) has been known to cause symptoms of digital ischemia (DI) in elite volleyball players. Studies have reported symptoms of DI in as much as 28% of the elite indoor volleyball players. The purpose of this study was to determine the diagnostic value of the Shoulder PCHA Pathology and digital Ischemia - Questionnaire (SPI-Q) for detection of sports related PCHA disease using ultrasound data as the standard of reference.

METHODS

The SPI-Q was completed by elite indoor volleyball players from the highest and single highest Dutch volleyball division and by elite beach volleyball players participating in the 2014 Grand Slam Beach Tournament The Hague (GSBTH). Ultrasound assessment of the dominant shoulder was performed on-site using the SPI-US protocol. The SPI-Q sensitivity, specificity, positive - and negative predictive value and positive - and negative likelihood ratios, and the diagnostic odds ratio were calculated for detection of sports related PCHA disease, using ultrasound as the standard of reference.

RESULTS

Two hundred twenty-four elite male indoor volleyball players from the Dutch division were included in this study and 62 elite male and female beach volleyball players participating in the GSBTH: a total of 278 players. Thirty-five percent of the players reported symptoms of DI. The prevalence of PCHA disease was 6.1%. For the SPI-Q we found a sensitivity of 18% (95% CI 4-43), specificity of 64% (95% CI 58-70), positive predictive value of 3% (95% CI 0.7-8.9) and negative predictive value of 92% (95% CI 87-96), positive likelihood ratio of 0.50 (95% CI 0.18-1.40), negative likelihood ratio of 1.28 (95% CI 1.01-1.62) and a diagnostic odds ratio of 0.39 (95% CI 0.11-1.38).

CONCLUSION

The diagnostic value of the SPI-Q to detect PCHA disease in elite volleyball players is poor, which makes it unsuitable as a diagnostic instrument for sports related PCHA disease specifically. However, it can be used to assess all-cause symptoms of DI and raise awareness within athletes and sports physicians, which is important for preventing ischemic complications.

Nonoperative Management and Novel Imaging for Posterior Circumflex Humeral Artery Injury in Volleyball

We report on a 34-yr-old male elite volleyball player with symptomatic emboli in the spiking hand from a partially thrombosed aneurysm of the posterior circumflex humeral artery (PCHA) in his dominant shoulder. At initial diagnosis and follow-up, a combination of time-resolved and high-resolution steady state contrast-enhanced magnetic resonance angiography (CE-MRA) enabled detailed visualization of: (1) emboli that were not detectable by vascular ultrasound; and (2) the PCHA aneurysm, including compression during abduction and external rotation (ABER provocation). At 15-month follow-up, including forced cessation of volleyball activities over the preceding 9 months, the PCHA aneurysm remained unchanged. Central filling defects in the palmar arch and digital arteries resolved over time and affected arterial vessel segments showed postthrombotic changes. Digital blood pressure values improved substantially and almost normalized during follow-up. In conclusion, this case report is the first to show promising results of nonoperative management for a vascular shoulder overuse injury in a professional volleyball player as an alternative to invasive therapeutic options.

Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics

Objectives

To determine the prevalence of posterior circumflex humeral artery (PCHA) aneurysms and vessel characteristics of the PCHA and deep brachial artery (DBA) in elite volleyball players.

Methods

Two-hundred and eighty players underwent standardized ultrasound assessment of the dominant arm by a vascular technologist. Assessment included determination of PCHA aneurysms (defined as segmental vessel dilatation ≥150 %), PCHA and DBA anatomy, branching pattern, vessel course and diameter.

Results

The PCHA and DBA were identified in 100 % and 93 % (260/280) of cases, respectively. The prevalence of PCHA aneurysms was 4.6 % (13/280). All aneurysms were detected in proximal PCHA originating from the axillary artery (AA). The PCHA originated from the AA in 81 % of cases (228/280), and showed a curved course dorsally towards the humeral head in 93 % (211/228). The DBA originated from the AA in 73 % of cases (190/260), and showed a straight course parallel to the AA in 93 % (177/190).

Conclusions

PCHA aneurysm prevalence in elite volleyball players is high and associated with a specific branching type: a PCHA that originates from the axillary artery. Radiologists should have a high index of suspicion for this vascular overuse injury. For the first time vessel characteristics and reference values are described to facilitate ultrasound assessment.

Key Points

• Prevalence of PCHA aneurysms is 4.6 % among elite volleyball players.

• All aneurysms are in proximal PCHA that originates directly from AA.

• Vessel characteristics and reference values are described to facilitate US assessment.

• Mean PCHA and DBA diameters can be used as reference values.

• Radiologists need a high index of suspicion for this vascular overuse injury.