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Allen Test
Authors

Jonah Zisquit1; James Velasquez2; Nicholas Nedeff3.

Affiliations
1 Kendall Regional Medical Center
2 Wyckoff Heights Medical Center
3 Kendall Regional Medical Center

Last Update: September 19, 2022.

Continuing Education Activity

The Allen test is used to assess collateral blood flow to the hands, generally in preparation for a
procedure that has the potential to disrupt blood flow in either the radial or the ulnar artery. These
procedures include arterial puncture or cannulation and the harvest of the artery alone or as part
of a forearm flap. A negative Allen test means that the patient likely does not have an adequate
dual blood supply to the hand, which may present a contraindication to the planned procedure or
at least suggest that further evaluation is necessary. This activity reviews the Allen test technique
and discusses the interprofessional team's role in applying this maneuver to improve patient
outcomes.

Objectives:

Identify the vessels evaluated by the Allen test.

Describe the indications for performing the Allen test.

Outline the technique for performing the Allen test.

Summarize interprofessional team strategies for improving communication in regards to the

significance of a negative Allen test.

Access free multiple choice questions on this topic.

Introduction
The Allen test (AT) is used to assess collateral blood flow within the hands, specifically testing for
the presence of a complete palmar arch.[1] Edgar Van Nuys Allen first described the test in 1929.[2]
Dr. Allen was a professor of medicine at the Mayo Clinic in Rochester, Minnesota, where he studied
peripheral vascular disease. He served as a colonel in the US Army Medical Corps in World War II
and led a distinguished career that included the presidency of the American Heart Association and
the receipt of the 1960 Lasker Award. In 1952, Irving Wright described a modified version of the
Allen test that has since largely supplanted the original method. It is referred to as the modified
Allen test (MAT). The MAT examines one hand at a time, in contrast to Allen's version, and can be
used to assess either radial or ulnar arterial flow.[3]

Anatomy and Physiology

Blood supply to the arms is carried by the left and right subclavian arteries, which arise from
the arch of the aorta - the left directly and the right via the brachiocephalic, or innominate, artery.
The subclavian arteries then run beneath the clavicle and become the axillary arteries as they pass
the lateral margins of the first ribs. From there, the axillary arteries become the brachial arteries
after passing the teres major muscles; they then supply blood to the upper arm, continuing distally
to the antecubital fossa, where they divide into the radial and ulnar arteries. The radial and ulnar
arteries supply blood flow to the forearm and eventually to the hand. The radial artery runs along
the lateral aspect of the forearm between the brachioradialis and flexor carpi radialis muscles. Just
distal to the wrist, it splits into superficial and deep palmar branches. The ulnar artery runs along
the medial aspect of the forearm and at the wrist runs through Guyon's canal, where it splits into
its deep and superficial palmar branches. These arches form the basis of collateral blood flow to the
hands.[4] The deep palmar arch is classically described as arising from the radial artery, with or
without contributions from the ulnar artery. The superficial arch is predominantly supplied by the
ulnar artery.[5] The deep arch of the hand is more commonly anatomically complete; thus, the
radial artery is more likely to provide the dominant blood supply, although the ulnar artery is
sufficient to perfuse the hand in 97% of cases.[6]

Indications
The need for this test arises in cases in which a procedure that may compromise radial artery
patency is being considered. A classic example is the harvest of a radial forearm flap wherein the
radial artery is included to perfuse the tissue being transferred and is therefore no longer available
to perfuse the hand. Likewise, if the radial artery needs to be cannulated or catheterized and there
is a risk for thrombosis, the Allen test can help confirm that the hand will maintain adequate blood
flow through the ulnar artery and collaterals in the event the radial artery becomes occluded. A
positive Allen test means that the patient may have an adequate dual blood supply to the hand. A
negative Alle test shows the patient may not have adequate dual blood supply, which would be a
contraindication for catheterization, radial forearm flap harvest, or any procedure that may result
in the occlusion of the vessel.[7][8]

Equipment
The Allen test may be performed with only a clinician's hands, although in some cases, a Doppler
probe placed on the thenar eminence or a pulse oximeter placed on the thumb may be helpful,
particularly if a patient exhibits Reynaud's phenomenon with cool and pale hands at baseline.
Intraoperatively, an Acland microvascular clamp and a Doppler probe may be used to confirm
preoperative Allen test results prior to ligation of the radial artery.

Technique
The original Allen test is performed by asking the patient to elevate both arms above the head for
thirty seconds in order to exsanguinate the hands. Next, the patient squeezes their hands into tight
fists, and the examiner occludes the radial artery simultaneously on both hands. The patient then
opens both hands rapidly, and the examiner compares the color of the palms. The initial pallor
should be replaced with the hands' normal color as the ulnar arteries restore perfusion. The test is
then repeated while occluding the ulnar arteries rather than the radial arteries. The time that it
takes for the normal color to return should indicate the degree of collateral blood flow. The test is
positive when there is a return of normal color to both hands during occlusion of either artery
alone. Persistent pallor in the palm indicates inadequate collateral blood flow to the hand.
The modified Allen test differs from the original Allen test mainly by examining the radial and/or
ulnar arteries in one hand and then repeating on the other side, if necessary. Traditionally, it is
performed by first having the patient's arm flexed at the elbow with the fist clenched tightly to
exsanguinate the hand. The ulnar and radial arteries are then compressed by the examiner's
thumbs simultaneously. The elbow is extended to no more than 180 degrees, avoiding
overextension as that could lead to a false-negative test. The fist is subsequently unclenched, and
the palm should appear white. The compression is then released from the ulnar artery while
maintaining pressure over the radial artery (see image and video). Once the compression is
released, the color should return to the palm, usually within 10 seconds. The test is repeated on the
same hand while releasing the radial artery first and continuing to compress the ulnar artery if
evaluation of radial collateral blood flow is required.

In a patient with normal, patent arteries, the color should return to the palms relatively quickly
(within 10 seconds unless the patient is cold) after the release of either artery. If pallor persists
within the palm after the patient unclenches their fist and one of the arteries is released, then the
test is negative and indicative of an occlusion within the artery that is being released. For example,
if the radial artery is compressed and palmar pallor persists, it indicates compromised blood flow
in the ulnar artery. The same is true if the ulnar artery is compressed and palmar pallor persists;
then the compromised blood flow is in the radial artery.

There are additional tools the examiner can use to make this test more accurate. Digital
plethysmography, duplex ultrasonography with dynamic testing, and pulse oximetry (often with
the sensor placed on the thumb tip) can all be used.[9] Concomitant use of pulse oximetry while
performing the Allen test is the easiest of these methods. The technique involves placing a pulse
oximeter on the thumb before compression to get a baseline saturation and waveform. The
examiner will then compress both radial and ulnar arteries until the waveform disappears and the
oxygen saturation falls to zero. The pressure on the ulnar artery is then released. The waveform
and the saturation are recorded. If these values are consistent with the baseline, it implies good
collateral flow.[9]

Complications
While there are no complications likely to occur from the use of this simple physical examination
maneuver, the most feared complication that can be avoided by performing an AT or MAT is
catastrophic hand ischemia and subsequent tissue loss if the radial artery is disrupted and the
ulnar artery is insufficient to maintain perfusion of the hand. Tissue loss would be most likely to
occur in the thumb and thenar eminence, as these areas are farthest from the ulnar blood supply.
In the event that iatrogenic interruption of radial arterial blood flow leads to hand ischemia, the
artery may need to be reconstructed with either primary anastomosis or with a vein graft.

Clinical Significance
The AT and MAT tests are used to ensure adequate collateral circulation in the hand prior to
performing any procedure that has the potential to interrupt blood flow in either the radial or
ulnar arteries. The test can also be used as a diagnostic tool for any number of disorders that
cause reduced vascularity in the arm. It is most commonly used to assess collateral flow to the hand
through the ulnar artery when the radial artery is going to be used for drawing samples for blood
gas analysis, cannulation for placement of arterial lines, cardiac catheterization, radial artery
harvest for bypass surgeries, and radial forearm flap harvest for reconstructive surgeries.
The radial artery is often selected as a puncture or vascular access site because it is often more
readily palpable than the ulnar artery. One of the risks associated with arterial punctures is
ischemia distal to the puncture site, which could compromise the limb if there is inadequate
collateral blood flow. Though ischemia is only a rare complication of arterial puncture, many
healthcare providers do not perform either the AT or MAT prior to accessing the radial artery
because there is conflicting evidence supporting the accuracy of this test in assessing ulnar artery
patency or adequacy of collateral circulation. A 2007 study by Kohonen et al. found that the MAT
had a 73.2% sensitivity and 97.1% specificity for determining circulatory deficits before radial
artery harvest for coronary artery bypass grafting.[10] 

A 2017 meta-analysis, however, reported a lower sensitivity of 93% and an interobserver

agreement rate of only 71.5%, casting some doubt on the test's usefulness.[3] Aragwal et al. more
recently acknowledged the MAT's high negative predictive value but advocated for follow-up
testing with one of the other objective methods mentioned above in the event of a negative MAT
result.[11]

Enhancing Healthcare Team Outcomes

Interprofessional team members, including physicians, physician assistants, nurse practitioners,
nurses, and respiratory therapists, should perform an Allen test before cannulating or otherwise
disrupting the radial artery. While uncommon, the rare patient may develop hand ischemia with
interruption of radial arterial blood flow; for this reason, consistent use of the Allen test can lead to
better patient outcomes.

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

References
1. Bartella AK, Flick N, Kamal M, Steegmann J, Kloss-Brandstätter A, Teichmann J, Hölzle F,
Lethaus B. Hand Perfusion in Patients with Physiological or Pathological Allen's Tests. J Reconstr
Microsurg. 2019 Mar;35(3):182-188. [PubMed: 30099730]
2. Allen EV. Thrombo-Angiitis Obliterans. Bull N Y Acad Med. 1942 Mar;18(3):165-89. [PMC free
article: PMC1933752] [PubMed: 19312256]
3. Romeu-Bordas Ó, Ballesteros-Peña S. [Reliability and validity of the modified Allen test: a
systematic review and metanalysis]. 2017 AbrEmergencias. 29(2):126-135. [PubMed: 28825257]
4. Tan RES, Lahiri A. Vascular Anatomy of the Hand in Relation to Flaps. Hand Clin. 2020
Feb;36(1):1-8. [PubMed: 31757342]
5. Gokhroo R, Bisht D, Gupta S, Kishor K, Ranwa B. Palmar arch anatomy: Ajmer Working Group
classification. Vascular. 2016 Feb;24(1):31-6. [PubMed: 25757609]
6. Patsalis T, Hoffmeister HE, Seboldt H. [Arterial dominance of the hand]. Handchir Mikrochir
Plast Chir. 1997 Sep;29(5):247-50. [PubMed: 9424450]
7. Bertrand OF, Carey PC, Gilchrist IC. Allen or no Allen: that is the question! J Am Coll Cardiol.
2014 May 13;63(18):1842-4. [PubMed: 24583303]
8. Biondi-Zoccai G, Moretti C, Zuffi A, Agostoni P, Romagnoli E, Sangiorgi G. Transradial access
without preliminary Allen test--letter of comment on Rhyne et al. Catheter Cardiovasc Interv.
2011 Oct 01;78(4):662-3; author reply 664. [PubMed: 20939044]
9. Habib J, Baetz L, Satiani B. Assessment of collateral circulation to the hand prior to radial artery
harvest. Vasc Med. 2012 Oct;17(5):352-61. [PubMed: 22814998]
10. Kohonen M, Teerenhovi O, Terho T, Laurikka J, Tarkka M. Is the Allen test reliable enough? Eur
J Cardiothorac Surg. 2007 Dec;32(6):902-5. [PubMed: 17889550]
11. Agarwal T, Agarwal V, Agarwal P, Thakur S, Bobba R, Sharma D. Assessment of collateral hand
circulation by modified Allen's test in normal Indian subjects. J Clin Orthop Trauma. 2020 Jul-
Aug;11(4):626-629. [PMC free article: PMC7355091] [PubMed: 32684700]
Figures

Download video file.(3.5M, mp4)

The Allen test helps to determine whether the ulnar artery will be able to provide sufficient
blood flow to the hand in the event of ligation of the radial artery, as in the case of radial
forearm flap harvest. Contributed by Marc H Hohman, MD, FACS

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