Peripheral Arterial-Anatomy (Microscopic)
-ART Wall Layers:
1. Intima: Innermost. Consist of single layer endothelial cells
2. Media: Middle. Consist of smooth muscle cells & elastic Connective Tissue. Circular pattern provides strength to an ART
3. Adventitia (Externa): Outermost. Consist of Connective tissue for strength & structure
*Vaso Vasorum (internal vessels that penetrate Adventitia to supply nutrients of Media & Adventitial Layer
-Arterioles:
-Smallest Art vessel. Consists of Intima & Media
-Capillaries:
-Microscopic branches of the smallest Arterioles. Consists of the Intima
-Supplies O2 & nutrients to Tissue & remove waste products
Peripheral Arterial-Anatomy ABD AO
-Located LT of midline & ANT to the spine
-Courses INF fr Diaph to L-4 (@ Umbilicus) where it Bif→CIA
-Normal diam is 2-3 cm, tapering @ BIF to approx 1.5 cm
-Enlarged if >3-4 cm
-Major Visceral branches:
-Celiac Art, SMA, Renal Art, IMA
UE Anatomy
-LT Subc A branches off AO Arch on LT side
-On the RT, Innominate art/Brachiocephalic A branches dir off AO Arch and turns into RT Subc A w/c turns → Axillary Art @ Lateral Level of 1st rib
Axillary Art → Brachial art & Bif →Radial/Ulnar
Peripheral Arterial-Anatomy UE
-Subc Art:
-Rt Subc Art=originates fr Innominate (Brachiocephalic art)
-Lt Subc Art=originates fr AO Arch
-Both are located POST to clavicle & course betw ANT middle scalene muscle & 1st rib
-Divided into 3 segments:
1. fr its origin to MEDIAL border of Scalenus ant muscle
2. POST to Scalenus ant muscle
3. fr LAT border of Scalenus ant muscle→outer border of 1st rib
Peripheral Arterial-Anatomy (Major Branches of Subc A)
-Vert A
-Thyrocervical A
-Dorsal Scapular A
-Internal Thoracic A
-Costocervical A
-Internal Mammary A=aka Internal Thoracic A often used for CABG
Peripheral Arterial-Anatomy (Axillary Art)
-Cont of Subc A originating @ LAT border of 1st rib & terminates @ lower border of the Teres Major Muscle
-Branches of Axillary A:
-Superior Thoracic A
-Lateral Thoracic A
-ANT circumflex humeral A
-Thoraco-acromial A
-Subscapular A
-Post circumflex humeral A
Peripheral Arterial-Anatomy (Brachial A)
-Continuation of Axillary A originating @ level of the head, humerus & extending to the bend of the elbow
-Initially lies MEDIAL to the humerus & courses ANT to the Antecubital fossa where it BIF→RADIAL & ULNART A
Peripheral Arterial-Anatomy (Radial A)
-Smallest of the Brachial A terminal branches
-Originates @ the Antecubital fossa & passes along LAT side of forearm (Radius) to the wrist where it cont→palm to form Deep Palmar Arch
Peripheral Arterial-Anatomy (Ulnar A)
-Largest of the Brachial A terminal branches
-Originates @ the Antecubital Fossa & passes along MEDIAL side of forearm (Ulnar) to the wrist where it cont→palm to form Superficial Palmar Arch
Peripheral Arterial-Anatomy (Palmar Arches)
-Superficial Palmar Arch: After Ulnar Art gives off a branch to Radial A, it terminates as Superficial Palmar Arch
-Deep Palmar Arch: After Radial Art gives off a branch to the Ulnar Art, it terminates as the Deep Palmar Arch
Peripheral Arterial-Anatomy (Digital Art of UE)
-Arise fr the Palmar arch to supply bl to the fingers
-Each Palmar Digital A has 2 Dorsal Branches:
1. Lateral Dorsal digital A: courses on LAT border of each finger
2. Medial Dorsal digital A: courses on MEDIAL border of each finger
LE Art Anatomy
-Abd AO bif @ the level of the 4th lumbar vertebrae creating the CIA's (Common Iliac Art)
-RT CIA is longer than the LT & crosses over the LT Iliac Vns
-CIA bif into Internal/External Iliac Art
LE Plantar Arch
Anterior Tibial Art
↳Dorsalis Pedis Art (DPA) major branch is Deep Plantar Art (dpa)
Post Tibial Art
↳2 major distal branches:
Lateral plantar art w/c unites w/ Deep Plantar art to form the Plantar arch
Peripheral Arterial Anatomy-LE (CIA)
-CIA: Originates @ level of 4th Lumbar Vertebra fr BIF of Distal ABD AO
-RT CIA: Is longer than LT & crosses ANT to LT Iliac Vn
-They branch→IIA & EIA @ the Lumbosacral junction
Peripheral Arterial Anatomy-LE (IIA)
-aka Hypogastric A
-Originates @ the BIF of CIA (EIA origin)
-Supplies Bl to walls & viscera of the pelvis, buttock, genitals & Medial Thigh
-BIF→ANT/POST IIA
-Gives rise to Mult branches that provide important Collaterals in the presence of EIA obstruction
Peripheral Arterial Anatomy-LE (EIA)
-Originates @ BIF of CIA (IIA origin)
-Longer than IIA
-Courses along Inner border of Psoas muscle fr BIF of CIA to the Inguinal Lig where they become the CFA
-Has 2 Dorsal branches:
1. Inf Epigastric A
2. Deep Circumflex Iliac A
Peripheral Arterial Anatomy-LE (CFA)
-Originates @ Inguinal Lig
-Continuation of the EIA
-Courses LAT to CFV & divides→DFA & SFA
Peripheral Arterial Anatomy-LE (DFA) or Profunda Femoris A
-Originates @ BIF of CFA
-Courses POSTEROLATERAL @ its origin & cont MEDIAL to femur where it terminates in DIST 3rd of the thigh as Perforating ART
-Supplies Bl→Thigh muscles: Adductor, Extensor & Flexor muscles
-Comm. PROX w/ CFA & DIST w/ POP A via its muscular branches w/c are critical Collaterals in SFA obstruction
Peripheral Arterial Anatomy-LE (SFA)
-Originates approx 4 cm below the Inguinal Lig
-Arises fr CFA
-Courses along ANTEROMEDIAL portion of the thigh
-@ the level of the Adductor Hiatus in the tendon of Hunter's canal
-Gives rise to the Genicular Art (an important collateral pathway) & then cont as the POP A
Peripheral Arterial Anatomy-LE (POP A)
-Continuation of SFA beginning @ the Adductor Hiatus INF to where the SFA gives rise to the Genicular Art
-Descends LAT & terminates @ the Popliteus muscle, dividing into ATA & Tibioperoneal Trunk
-Has Mult genicular branches that supply bl to the knees
-Major branches incl Gastrocnemius Art w/c supply the gastrocnemius muscle in the calf
Peripheral Arterial Anatomy-LE (ATA)
-1st Branch off the DIST POP A
-Courses betw Tibia & Fibula, ANT along Interosseous Membrane, terminating as the Dorsalis Pedis Art (DPA) on ANT surface of the foot
-Supplies Bl to ANT LAT aspect of leg & portions of the foot
-DPA: Originates as terminal portion of the ATA on dorsum of the foot & travels toward the base of the great toe
Peripheral Arterial Anatomy-LE (Tibioperoneal Trunk)
-Second branch off the DIST POP A
-This very short segment quickly gives rise to the PTA & PERO Art
Peripheral Arterial Anatomy-LE (PTA)
-A Branch of the Tibioperoneal trunk
-Courses POST to the Tibia, behind Medial Malleolus
-Terminates→MEDIAL & LATERAL Plantar Art in the foot, below the Medial Malleolus (inner ankle)
-Supplies Bl to the Sole of the foot
Peripheral Arterial Anatomy-LE (Peroneal A)
-Arises @ the DIST end of the Tibioperoneal trunk
-Courses along the MEDIAL border of the Fibula terminating as the External Calcaneal A
-Suppl Bl to the LAT aspect of leg & heel of the foot
-Plantar Arch: Formed fr Deep Plantar Art (branch of DPA) and LAT Plantar A (branch of the PTA)
-Gives rise to the Dorsal Metatarsal branches w/c supply Bl to the digits of the foot
Peripheral Art-Controllable Risk Factors (DIABETES)
-Alters progression & distribution of atherosclerotic disease
a. Contributes to hardening of ART wall & loss of elasticity=ART incompressible
b. Referred to as Medial Calcinosis
-Leads to small vessel disease of lower leg
-Can lead→gangrene & necrosis=amputation
-Can lead→trauma due to neuropathy
Peripheral Art-Controllable Risk Factors (HYPERTENSION) HTN/HYPERLIPIDIMIA
-HTN:
-High BP
-Assoc w/ development of Atherosclerosis, HTN causes ↑ in Intraluminal ART wall stress
-HYPERLIPIDIMIA:
-↑ Saturation of lipid fats in Bl contributes to development of Atheromatous plaque
Peripheral Art-Controllable Risk Factors (SMOKING)
-Strong risk factor in development of Atherosclerosis
-Nicotine has many harmful effects incl:
1. Recurr Vasoconstriction in Arterioles & Capillaries
2. ↑ BP
3. ↑ Myocardial Oxygen demand
4. ↑ Platelet aggregation
5. ↑ Cholesterol levels
Peripheral Art-Uncontrollable Risk Factors
-Incr age
-Family Hx
-Male gender
-Thrombophilia: hereditary risk toward development of thrombus (Bl clot)
Peripheral Art-Mechanisms of Disease
1. Atherosclerosis: Hardening, thickening & loss of elasticity in the ART walls
2. Embolism: Bl clot or foreign substance that travels in Bl stream causing blockage. May be solid, liquid or gas
3. Aneurysm: Involves all 3 layers of the wall for it to be a TRUE aneurysm
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Arteritis
-Inflammation of an ART wall
1. Takayasu Arteritis: Type of Giant Cell arteritis originating in the AO & progresses outward
-Known as 'pulseless' disease (diminished pulses over a period of time)
-2. Temporal Arteritis: Inflammation of Temp A= visual changes or loss of vision
-3. Polyarteritis Nodosa: Systemic disease affecting small & med sized Art
-Inflammation destroys Media layer causing aneurysm formation
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Buerger's Disease
-aka Thromboangitis Obliterans (TAO)
-MOST common Arteritis affecting DIST ART of hands & feet
-Assoc w/ heavy cigarette smoking in Men <40 y/o
-Rest Pain & Ischemic ulcers occur early
-Assoc w/ collagen vascular syndromes such as rheumatoid arthritis & lupus
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Vasopastic Disorders
1. Raynaud's Syndrome
2. Coarctation of the AO
3. Entrapment Syndromes
4. Popliteal Cystic Disease
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Vasospastic Disorder=Raynaud's Syndrome
1. Primary: aka Raynaud's Disease
-Intermittent digital ischemia caused by prolonged digital vasospasm fr exposure to cold, chemicals (nicotine) or occupational trauma (vibration inj) to hands
-Commonly seen in Young women
-NO known underlying disease process
2. Secondary: aka Raynaud's Phenomenon
-Vasospasm assoc w/ Underlying autoimmune disease, connective tissue disease (scleroderma) or fixed obst disease
-Ischemia is CONSISTENTLY present
*PRIMARY=Vasospasm w/ NO underlying dis
*SECONDARY=Vasospasm SECONDARY to underlying disease
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Vasospastic Disorder=COARCTATION OF THE AO
-Congenital narrowing of AO Arch or Thoracic AO
-Clinical findings:
-1. HTN fr ↓ Kidney perfusion
-2. BILATERALLY ↓ LE pulses
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Vasospastic Disorder=Entrapment syndromes
-1. POP ENTRAPMENT: Defect where there is compression of the POP A by MEDIAL head of the Gastrocnemius muscle
-Commonly found in young Males & is BILAT in 1/3 of pts.
-2. THORACIC OUTLET COMP SYNDROME (TOS): Compression of the Subc A, @ the Thoracic outlet by the scalene muscles, cervical rib or clavicle
-Sx can be a combo of Vascular/Neurologic
Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Popliteal Cystic Disease
-Baker's Cyst: Cystic dilatation of Gastrocnemius-semimembranous bursa located in POP Fossa (POST & MED to knee joint)
-Common in pts w/ severe degenerative joint disease or rheumatiod arthritis
-Large cysts are prone to rupture causing pain, tenderness & swelling of calf
Peripheral Art-Signs & Sx: Chronic Occlusive Disease (Claudication)
-Claudication of LE: Progressive, reproducible, muscular pain in THIGH, BUTTOCK, or CALF after exercise
-Caused by ↓ Bl perfusion to muscle tissue during exertion & is relieved by stopping the exercise
-Sx: Pain, cramping, fatigue or tightness of the leg
-Usually PROX to location of sx
-1. BUTTOCK &/or THIGH pain=Aortoiliac Occlusive Disease if BILAT; PROX FEM
-2. THIGH pain=DIST EIA &/or CFA disease
-3. CALF pain=SFA &/or POP A disease
**Vascular Claudication is: Pain w/ exercise for a predictable distance, Relieved by rest & ALWAYS reproducible
Peripheral Art-Signs & Sx: Chronic Occlusive Disease (PSEUDOCLAUDICATION)
-Leg w/ exercise NOT due to Vascular obstruction but may mimic symptoms of True Vascular Claudication
-Usually neurogenic or musculoskeletal in etiology
-NOT predictable
-Only relieved if rest is non-weight bearing
Peripheral Art-Signs & Sx: Chronic Occlusive Disease (Ischemic Rest Pain)
-Persistent pain in feet & toes due to ↓ Bl perfusion
-Occurs while sleeping when BP is LOW & limb is Elevated
-Indicates ADV Art Occlusive Disease
-Relief: Place foot in a dependent position to ↑ Gravitational & Hydrostatic Po
Peripheral Art-Signs & Sx: Chronic Occlusive Disease (Tissue Loss)
-Gangrene & necrosis represents the most Severe form of Ischemia
-Results fr Insufficient or absent Bl supply to the tissue
-Ulceration is common on dorsum of foot or toes; ANT Tibial area=Deep, reg in shape & painful
-Revascularization or amputation is usually required
-Look @ ART & VENOUS Ulcers for differentiation
Peripheral Art-Signs & Sx: Acute ART Occlusion
-Caused by an Embolus, Thrombosis or Trauma
-Sx: "6 P's"
-1. Pain: severity depends on degree of ischemia
-2. Pallor
-3. Pulselessness
-4. Paresthesis: numbness/tingling of skin
-5. Paralysis
-6. Poikilothermia: Coldness of skin
Peripheral Art-Signs & Sx: Vasospastic Disorders
-Abnormal Vasospasm of digital Art in hands or feet induced by exposure to cold
-Sx:
-1. Pain
-2. Paresthesia
-3. Skin color changes
-Pallor: White
-Cyanosis: Blue
-Rubor: Red
*MOST common digital cold sensitivity condition is Raynaud's Syndrome
Peripheral Art-Signs & Sx: Physical Examination
(Skin Dermal Changes & Temperature)
-Color:
-Pallor: deficient Bl supply when legs are elevated
-Rubor: Vasodilation when legs are in a dependent position (aka Dependent Rubor) & Bl pools→Arterioles due to gravity
-Cyanosis: Fr Deoxygenated Bl
-Temperature: Warm vs. Cold
-Symmetrical coolness=Vasoconstriction
-Asymmetrical coolness=ART insufficiency in leg that is cool
Peripheral Art-Signs & Sx: Physical Examination (Capillary Filling & Trophic Changes)
-Capillary filling: An ↑ in Capillary refill time indicates ↓ ART perfusion
-Trophic Changes: Indicates poor tissue nutrition fr ART insufficiency
-Hair loss over toes & dorsum of foot
-Thin, shiny, smooth or scaly skin
-Thickened, brittle toenails
Peripheral Art-Signs & Sx: Physical Examination (Palpation of pulses)
-Evaluates for Pulses & Aneurysms
-Eval presence, strength & regularity of puls
-Locations for LE:
-AO, Groin (CFA), POP FOSSA (POP A), Foot (PTA & DPA)
-Locations for UE:
-CCA, AXILLARY A, BRACHIAL A, RADIAL/ULNAR A
-Rate of Pulses:
-0= NONE 1+=Weak 2+=NORMAL
-3+=Strong 4+=Bounding
-May also Indicate Aneyrysmal
Peripheral Art-Signs & Sx: Physical Examination (Auscultation of Pulses)
-Using a Stethoscope, eval for Presence, Duration & Strength of BRUIT
-BRUIT: 'Noise' indicates TURBULENT Bl flow caused by Stenosis w/in the Art
-It is a vibration transmitted to surrounding tissue & is caused by flow disturbances in the vessel.
-'Vibrations' or 'Thrills' may be due to a Fistula, Poststenotic Turbulence or a Dialysis graft
-Locations for LE: ABD AO, CFA, POP A
-Locations for UE: ♡, CCA, Subc A
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po Meas
-(UE/LE)
-1. RATIONALE: Provides physiologic info & confirm vascular etiology for Claudication & Ischemic Rest Pain
2. CAPABILITIES:
-Screens for presence, level & severity of Atherosclerotic Occlusive Disease
-Provides Info for baseline & follow-up treatment
-Diff Vascular sx fr Neurologic or Musculoskeletal disorders
-Helps diff True Art Disease fr cold sensitivity/Vasospasm of digits
-Aids in prediction of wound/ulcer healing
-Toe Po <30 mmHg=Poor healing potential
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po Meas -Limitations-
-Can't distinguish Stenosis fr Occlusion
-No Exact location of disease
-Mult level disease may hinder an accurate loc
-Ca++ (medial calcinosis) falsely elevated (in Diabetic pts or pts w/end stage renal disease)
-Large thigh girth=falsely ↑ Po
-Vasoconstriction affects results
-Ulcerations, gangrene & bandages limit placement of cuffs & PPG sensor for digital Po
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po
-Cuff Sizes-
-S/b 20% wider than diameter of limb for accurate Po recording
-Should fit snugly, but not tight
-Small cuff=Falsely elevated BP
-Large cuff=Falsely ↓ BP
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po
-3 Cuff vs. 4 Cuff Technique-
-3 Cuff:
-1 large cuff on THIGH (17-22 cm)
-1 cuff on the CALF (12 cm)
-1 cuff on ANKLE (10 cm)
-4 Cuff:
-1 (12 cm) cuff on HI THIGH
-1 (12 cm) cuff ABOVE the KNEE
-1 (10 cm) cuff BELOW the KNEE
-1 (10 cm) cuff @ THE ANKLE
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po
-ADV & DISADV-
-4 cuff: useful in diff Inflow fr FEM Art disease. HI THIGH cuff Po artifact may occur
-Cuff artifact: Falsely ↑ HI THIGH Po 20-30 mmHg > Brachial Po
-3 cuff: Uses 1 large cuff on the THIGH
-NO artifact produced
-Can NOT diff betw Inflow & FEM Art disease
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po
-Exam Protocols-
-Positioning:
-UE: Supine w/ arms @ pts sides
-LE: Supine w/ legs @ same level as ♡
-UE
-12x40cm cuff: Brachial
-10x40cm cuff: Forearm & Wrist
-Obtain Po Bilat fr upper arm w/ CWD on Brachial Art. Radial/Ulnar used to obtain Po fr forearm
-LE
-Determine if 3 or 4 cuff method will be used
-Obtain Bilat Brachial Po
-Obtain Po starting @ ankles then up the leg
-CWD placed over DPA or PTA & Po are taken, Art w/ highest reading will be used in obtaining rest of the Po
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po
-Interpretation of Po in UE-
-DIFF of 20 mmHg or more betw Brachial Po=Innominate, Subc, Axillary or PROX BA Occlusive disease on the side of the ↓ Po
-Po fr wrist & forearm s/b ≥ Brachial Po
-↓ in Po of >15-20 mmHg fr wrist/forearm=
1. BA obst DIST to upper arm cuff
2. Obst in both Radial/Ulnar Art
3. Obst in either R/U A (single A); Art w/ ↓ Po
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po
-Interpretation of Po in LE-
-Obtain ABI for ea LE
-ABI=Highest Ankle Po (PTA or DPA) ÷ Highest Brachial Systolic Po
-W/ 4-cuff method, HI THIGH Po s/b 20 mmHg or > Brachial Po
-Low HI THIGH Po=Inflow Disease
-Diff betw segments (or BP cuffs) & limb to limb Po=20 mmHg or < to be NORMAL
ABI Interpretation Criteria
1.0 but <1.4: Normal (>1.4=Art Medial Ca++)
0.9-1.0: Minimal Art Disease
0.5-0.9: Claudication (Single level disease)
0.3-0.5: Ischemic Rest Pain (Multi level dis)
<0.3: Tissue loss/gangrene
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Digital Po Positioning-
-Fingers: Pt can sit w/ arms @ sides & hands resting on lap
-Toes: Pt is Supine w/ head slightly elevated
-Pt s/b kept warm
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Digital Po Technique-
-Waveforms can be obtained using CWD or PPG
-Toe cuffs s/b @ least 1.2x of the toe girth & first obtain ABI to r/o PROX disease
-Finger cuff size= 2 - 2.5 cm
-Disease w/ specific testing: Fingers w/ cold stress for Raynauds:
1. Hands are immersed in ice water for 3 mins
2. Waveforms & Po taken immed upon removal fr immersion & @ 5 mins post stress
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Digital Po Interpretation-
-Toe Po & TBI are useful in assessing small vessel disease in toes/foot
-Used when ABI canNOT be used due to Ca+ art
-TBI: Highest Brachial Po ÷ Toe Po
-TBI >0.66 or 0.7=NORMAL; <0.66: Abnormal
-FBI: 0.8-0.9=NORMAL; Finger Po may be ↓ if digits are Cold
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Constant-load Treadmill Exercise Testing-
-Performed on pts that present w/ Claudication & has a normal @ rest Physiologic study
-Test is performed to reproduce pts Sx
-Exercise should induce Peripheral Vasodilatationin the microcirculation so DIST peripheral R ↓ & flow ↑
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Constant-load Treadmill Exercise Testing- Limitations
-Pt w/ ff risk factors or conditions should not be exercised on treadmill:
-♡ condition (ie Angina or myocardial infarct)
-Hypertension
-COPD
-Poor ambulation
-Ischemic Rest Pain or ABI <0.3
-Acute DVT
-Ulceration or gangrene
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Constant-load Treadmill Exercise Testing-Protocol
-Place BP cuffs (upper arm & both ankles)
-Pt walks @ 1.5-2 mph w/ 10-12o elevation
-Pt should walk for a MAX of 5 mins or until sx prevent them fr continuing
-Immed ff exercise, Po are obtained fr both ankles & arm & ABIs are calculated
-Post exercise, Ankle Po/ABIs s/b documented beginning w/ symptomatic leg
-Repeat Po @ 2-min interval for 10 mins or until ABIs return to Pre-exercise levels
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Constant-load Treadmill Exercise Testing-Interpretation Post Exercise
-NORMAL: Ankle Po ↑ slightly post-exercise or ↓ slightly but return to resting Po w/in 1 min
-ABNORMAL: ankle Po ↓ Post-exercise
-Single level disease: ABIs ret back to normal w/in 2-6 mins
-Multi-level disease: ABIs remain ↓ for 12 or more mins
-Post exercise Po <60 mmHg=Critical Ischemia
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia-
-Used in place of treadmill testing on pts who can NOT tolerate walking (ie Asthma, ♡ condition, amputation)
-Used to measure the ability of vessels to VASODILATE after a period of induced Vasodilatation & Ischemia
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia- Capabilities & Limitations
-Capabilities:
-Docs effects of Occlusive disease in pts who are unable to move at the time of exam
-Limitations:
-Poor pt tolerance due to PAIN
-Does NOT simulate walking
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia- Exam Protocol
-Cuff placed around Low thigh & inflated to suprasystolic Po (20-30 mmHg above ↑est Brachial BP)
-Maintain Po for 3-5 mins to produce Ischemia & Vasodilatation DIST to the cuff
-Immed upon rapid deflation of cuff, obtain Brachial & Ankle Po
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia- Interpretation
-NORMAL:
-Mild drop in ankle Po 17-34%
-ABNORMAL:
-Single level: approx 50% drop in ankle Po
-Multi level: >50% drop in ankle Po
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Toe Raises & Limitation-
-May be substituted for Treadmill & Reactive Hyperemia in SYMPTOMATIC pts that can NOT move due to ♡ condition, COPD, etc
-Limitation:
-Does NOT reproduce Sx of Claudication nor does it use same muscles as walking does
-Symptomatic calf pain after toe raises may be due solely to Fatigue
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Toe Raises Protocol-
-Pt stands flat, then rises on toes, then ret to standing flat
-Toe raises repeated up to 50x or until pt can NOT cont.
-Record # of toe raises & onset of pain
-Immed after exercise, obtain Po fr Arm & Ankle
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PVR & Capabilities-
-aka Pneumo or Air Plethysmography
-Records Vol changes in a limb related to Pulsatile Art flow
-Capabilities:
-Assesses overall flow to limb segment
-Not affected by Ca+ Art
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PVR & Limitations-
-Can NOT distinguish Stenosis fr Total Occlusion
-Can NOT ID disease segments DIST in presence of severe PROX dis
-Can NOT Diff betw major ART & Collateral branches
-Obesity & Edema = False + results
-Waveforms affected by room temp, basal state & medications
-Digits w/ Po <20 mmHg may NOT generate a waveform
-Pt w/ resting muscle tremors=Waveform artifacts
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PVR- Pt Positioning & Protocol
-LE: Supine w/ legs @ same level as the ♡
-Protocol: Use 3 or 4 cuff method
-Inflate cuffs sequentially (HT→DIST) 65 mmHg
- As bl flow moves UNDERNEATH Cuff thru ART, branches, small vessels & any Collaterals ↑ in limb segment vol occurs during systole
-These increases change girth of extremity, putting Po against cuff bladder
-Cardiac Cycle Vol changes are recorded on Plethysmograph for ea cuff segment
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PVR & Interpretation of Waveforms-
-Combo of Qualitative & Quantitative assessment
-Both AMP & Contour of waveform is considered
-
-NORMAL: Sharp Systolic upstroke, Narrow Systolic peak, Prominent DN on downslope
-MILDLY Abnormal: Slight loss of AMP, loss of DN, slight bowing of downslope away fr baseline
-MODERATELY Abnormal: Flattened systolic peak, loss of DN & a reduced rise time in systole
-SEVERELY Abnormal: Very LOW AMP & broadening of wave contour or flat line
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG-
-Detects & Records Cutaneous Pulses using Infrared light-emitting diode (sensor)
-Light is transmitted→capillary beds(microcirculation) & portion of it is reflected back to a photosensor
-Waveform represents flow present in microcirculation
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Uses & Capabilities-
-Uses:
-Evaluates ART disease w/in the digits
-Can be used to assess skin perfusion (wound healing potential) & for digital cold sensitivity testing
-Capabilities:
-IDs vascular etiology (ie Blue toe syndrome)
-Differentiates small vessel atherosclerotic disease fr vasospastic disorder
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Limitations-
-Qualitative assessment only
-Significant PROX Art dis reduces digital perfusion & eliminates ability to eval small vessel art in digits
-Vasoconstriction affects Quality of exam (Hands/feet must be warm & calm)
-Incorr application or poor skin contact of sensor=Artifact & poor quality
-Digital Po <20 mmHg may NOT generate a waveform
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Protocol- Toe/Finger Testing
-Supine or sitting w/ arms @ side & hands resting in lap
-Obtain Resting waveform by placing sensor underneath toes/fingers using double sided tape
-Record Resting waveform
-If Po are needed, apply a Toe/finger cuff around toe/finger. Inflate until waveform disappears. Deflate & document Po when waveform reappears
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Protocol-
Cold Immersion Stress Test
-This Test documents results in response to Cold Exposure
-Record Resting waveform using PPG sensor applied underneath ea finger
-Immerse hands in ICE cold H2O for 3 mins
-Immed obtain waveforms & then 5 mins after immersion
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Interpretation of Waveforms-
-Normal to Severely abnormal same as PVR analysis
-Peaked Pulse Contour: Assoc w/ Digital Vasospasm=Pointed peaked waveform w/ an anacrotic notch on upslope & DN high on downslope
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -CWD Capabilites/Limitations-
-Capabilities:
-Effective & simple screening test for presence of PVD esp Atherosclerotic Occlusive Dis
-Limitations:
-Requires skill & experience
-Doppler may be attenuated by scar tissue, hematoma or Ca+ plaque in the Art
-Dampened waveforms seen in CHF
-MAJOR Limitation: Inability to localize specific segment of disease
Peripheral Art: Non-Invasive Test Procedures
(DIRECT Testing) -CWD Analog vs CWD-
-Analog Doppler uses a Zero-crossing F meter to display signals graphically on a strip chart recorder
-CWD displays single-line trace of Avg F shift
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -CWD Qualitative Interpretation-
-Qualitative Interpretation:
-Normal: HI Resistant waveform (triphasic)
-Rapid Systolic upstroke, early diastolic reversal & late diastolic oscillaiton
-Abnormal: Monophasic, Non-pulsatile, or Absent as disease progresses
-Loss of Reverse component
-@ the site of Stenosis, V ↑ in pitch & Amp
-DIST to a HDS Stenosis=Dampened signal w/ LESS prominent Systolic component w/ absence of diastolic sounds
**DIASTOLIC component tells what is happening DISTAL to the sample
DDDs=Decreased Diastole, DIST to Disease
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -CWD Quantitative Interpretation- PI
-Diff Inflow fr Outflow disease
-Can be obtained fr Analog or Spectral Waveforms (Spectral Analysis is MORE sensitive than Analog waveforms)
-Normal values: usually ↑ fr Central to Peripheral Vessels
-CFA: >5.5
-POP A: 8
-PTA: 14
Abnormal Values:
-CFA: <5
-In the absence of SFA disease, PI of <5=Aorto-Iliac disease
**There is an INVERSE Rel betw Art disease & PI: If NO Art dis present=PI is HIGH
As the severity of ART dis ↑, PI ↓
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -CWD Quantitative Interpretation- Acceleration Time (AT)
-Meas time fr onset of Systole to point of Maximum Peak Vel
-Diff Inflow fr Outflow disease
-Shortened AT=Normal suggesting absence of flow reducing disease
-↑ or Prolonged amt of time=Significant PROX disease is present.
-AT will NOT be prolonged w/ disease DIST to level of insonation
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow Imaging- Capabilities
-Ability to indicate Exact location of disease & determine if a segment is stenosed or totally occluded
-Detects/Diff Aneurysms, Pseudoaneurysms, Hematoma, AV fistulae, Graft patency
-IDs Collaterals
-FF up & monitor disease progression, medical therapy, surgical and/or interventional procedures
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow Imaging- Limitations
-Time consuming
-Requires skill & experience
-Pt body habitus=obesity & edema
-Ca++ in ART walls may block segments of ART
-Bandages, casts, surgical incisions, staples, sutures or open wounds on extremities=Limited Visualization of ART
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow Imaging- Pt Positioning
-UE: Supine w/ arms relaxed @ side
-LE: Supine. Hips externally rotated w/ knee slightly bent
-Use 5, 7.5 or 10 MHz Linear Tx for FEM, POP, TIBIAL ARTS or SUBC/Brachial Art)
-Use 2.0-3.5 MHz Phased Array Tx for Deep vessels (ie AO, Iliac Art)
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow Imaging- Protocol LE
-Eval (w/ 2-D in SAG & TRV, Color & Spectral Doppler) ff ART for presence, location, size & characteristics of plaque &/or thrombus:
-DIST EIA
-CFA
-DFA or Profunda Femoris
-SFA
-POP A
-Tibioperoneal Trunk
-ATA
-PTA
-PERO A
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow Imaging- Protocol UE
-Eval (w/ 2-D in SAG & TRV, Color & Spectral Doppler) ff ART for presence, location, size & characteristics of plaque &/or thrombus:
-SUBC A
-AXILLARY A
-BRACHIAL A
-RADIAL/ULNAR A
Peripheral Art: Non-Invasive Test Procedures
(DIRECT Testing) -Duplex/Color Flow- Imaging & Spectral doppler technique
-Assess w/ Color Doppler & 'mapping' regions of flow disturbances w/ Spectral Doppler
-If Stenosis is seen w/ B-Mode &/or Color Doppler, obtain Spectral Waveforms fr:
-PRE Stenotic, MAX Stenotic, & POST Stenotic regions
-Meas PSV fr various regions
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- 2D Interpretation
-Normal:
-No Intraluminal echoes w/in vessel
-Abnormal:
-Intraluminal echoes w/in vessel lumen
-POST Shadowing fr Ca+ Art wall
-Narrowing of vessel lumen
-Measurements:
-Diameter vs. Area
-Spectral Waveform Analysis is the PRIMARY method for classifying severity of disease
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation NORMAL Flow characteristics in Native ART
-LE:
-Normal Triphasic signal
-Loss of Flow Reversal in Diastole is Normal fr Vasodilatation due to Reactive Hyperemia or Limb warming
-NO established criteria for UE disease
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation NORMAL Flow characteristics in Bypass Grafts/Stents
-Monophasic for 1st several weeks POST-OP (due to Vasodilatation)
-Normal Triphasic signal w/in minimal Spectral Broadening
-VEL >45 cm/s obtained fr smallest diameter segment of graft
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in STENOSIS
-VEL ↑ as Bl flows thru a Stenosis
-Disturbed flow occurs DISTALLY as vessel lumen returns to normal
-50% DR=75% AR is considered HDS (Hemodynamically Significant)
-If there is Severe ↓ in Po & Flow=HDS
**Bl flow becomes increasingly limited as # of Stenotic lesions ↑ w/in a vessel segment
-Ischemia cause DIST Arterioles to remain dilated allowing more Bl flow to tissues resulting in MONOPHASIC waveform
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation
ABNORMAL Flow characteristics in STENOSIS Profile
-PROX:
-Vel are usually Dampened
-@ Entrance, w/in Stenosis, & @ Exit of Stenosis:
-Vel ↑ w/ Spectral Broadening; Flow becomes Disorganized
-DIST to Stenosis:
-Post Stenotic Turbulence w/ Flow reversals, flow separations, Vortices & Eddy Currents
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing)-Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in Collateral effects
-W/ severe Disease, flow @ rest may be Normal due to development of collateral network
-Locations of collateral vessels help indicate obstruction level
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation LE: Abnormal PSV @ a stenosis compared to Pre-Stenotic PSV
-2:1 ratio = >50% DR
>200 cm/s = >50% DR
-4:1 ratio = >75% DR
>400 cm/s = >75% DR
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in Occlusion
-B-mode interrogation of vessel may appear normal
-Color Doppler produces an image free of any color flow w/in occluded segment
-Spectral Doppler will NOT provide any info in area of occlusion
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in Bypass grafts/stents
-Compare PRE & POST stenotic VEL
-2:1 ratio = > 50% DR (>200 cm/s)
NOTE: It is a NORMAL finding to observe retrograde flow into the bypassed segment of the Native Art due to ↓ Po
-Waveform converts fr Tri to Biphasic
-Monophasic waveform
-Staccato Doppler signal (indicates HR fr DIST lesion or Obst to Outflow)
-Extensive Spectral Broadening
-Turbulent Color flow
-Intraluminal Echoes on B-mode
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in Aneurysm
-↑ in Diameter of 50% or > the native Art is considered Aneurysmal
-B-mode: documents bulging Art wall & obtain measurements of TL & RL in both SAG & TRV planes
-Color doppler: Document RL in both SAG & TRV planes
-Spectral doppler waveforms obtained w/in RL to detect abnormal flow
-Most common Peripheral Art Aneurysm is in POP A; POP aneurysms can occlude vessel leading to Sx of Acute Ischemia
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in Pseudoaneurysm
-FEM Pseudoaneurysms usually occur ff ART punctures fr Angiography or Angioplasty
-Bypass graft anastomotic failure or rupture
-Color Doppler: 'Yin-yang' sign w/ possible thrombosis w/in false lumen
-Spectral Doppler sampling=to-and-fro flow
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Interpretation ABNORMAL Flow characteristics in a Trauma
-Penetrating Trauma is the MOST common cause of NON-Iatrogenic inj to Bl vessels (ie gunshot wounds, knife wounds)
-Duplex evaluation is indicated in pts w/ an extremity/brachial index in the affected limb of <0.9
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Qualitative Interpretation
-Arterial flow Qualitative interpretation is described as Tri, Bi or Monophasic
-Turbulence of flow, seen as Spectral Broadening, is usually noted in late Systole & early Diastole, as the 'filling in' of the spectral window indicates disease fr mild to severe
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) -Duplex/Color Flow- Spectral Doppler Quantitative Interpretation
-PSV:
-Reflects the MAX Acceleration of flow during the Cardiac cycle
-EDV:
-Reflects the Resting stage of the Cardiac cycle, before the onset of the next cardiac contraction
-NOTE: Systole=PROX disease
Diastole= DIST disease
Evaluate Systole first
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) Duplex/Color Flow
Spectral Doppler Quantitative Interpretation Velocity Ratio
-Qtfys ART disease in pts w/ multilevel disease
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) Duplex/Color Flow Spectral Doppler Quantitative Interpretation
Pulsatility Index
-Numerical indicator of Distal Resistance
-Used to differentiate Inflow fr Outflow disease; as severity of ART dis ↑, PI ↓
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) Duplex/Color Flow Spectral Doppler Quantitative Interpretation
Resistive Index
-Numerical indicator of Resistance
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) Duplex/Color Flow Spectral Doppler Quantitative Interpretation
Acceleration Time
-Measures time fr onset of Systole to point of MAX Peak Vel
-An ↑ or prolonged Amt of time indicates significant PROX disease
-Incorrect Doppler angle can Over/Under estimate Disease
Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) Duplex/Color Flow Color Doppler Interpretation
-Locates & IDs presence or absence of flow w/in a vessel
-IDs Direction of flow in relation to the Tx
(Blue Away Red Toward)
-Qualitatively assesses flow characteristics:
1. Accelerated flow
2. Turbulent flow
3. Normal Systolic & Diastolic flow components in relation to Spectral Analysis
Peripheral Art: Correlative &/or Prior Imaging
Conventional Angiography
-Method: Seldinger Technique
-Thin catheter is inserted→ CFA, AXILLARY, or Brachial Art
-Contrast agent is inj thru catheter & highlights ART lumen
-Images of highlighted vessels of interest are recorded
Peripheral Art: Correlative &/or Prior Imaging DSA
-Same technique used in Cerebrovascular
Peripheral Art: Correlative &/or Prior Imaging Interpretation
-Compares RL diameter @ the lesion to the Normal vessel lumen just DIST to the lesion gives a %DR
-Arteries or specific areas w/in ART lumen that do NOT opacify suggest Occlusion or Stenosis respectively
-Vessels are studied for evidence of Ulceration or other disease
Peripheral Art: Correlative &/or Prior Imaging Limitations
-Same as Cerebrovascular
-Anaphylactic reaction, renal failure or hemorrhages @ the site of ART puncture are possible risks
Peripheral Art: Correlative &/or Prior Imaging CTA Computed Tomographic Angiography
-Uses Contrast to examine bl flow in the ART
-Computer instrumentation obtains images fr mult locations using many views
-Can convert a 2-D to 3-D image
-Contraindicated in pts w/ sensitivity to contrast medium
Peripheral Art: Correlative &/or Prior Imaging
MRA Magnetic Resonance Angiography
-Vascular imaging technique using Radio waves in a strong magnetic field to produce 2-D & 3-D images of bl vessels w/o use of contrast agents
-Contraindicated in pts w/ metal surgical clips, pacemakers or metal implants
Peripheral Art: Treatment
1. Medical Therapy
2. Surgical Therapy
3. Endovascular
Peripheral Art: Treatment Medical Therapy
-Control or reduction of risk factors incl obesity, high cholesterol, hypertension & tobacco use
1. Lifestyle changes: Wt control
2. Dietary changes: Low cholesterol diet to enhance normal endothelial metabolism
3. Incr in amt of exercise: To promote development of collateral circulation & ↓ BP
4. Stop smoking: Nicotine causes Vasoconstriction & irritates the endothelium
Peripheral Art: Treatment Medical Drugs
-Anticoagulants:
1. Heparin or Lovenox administered either thru IV or by subcutaneous inj, prevent bl coagulation & prevent ext of thrombus, NOT to dissolve it
2. Warfarin is taken orally after Heparin or thrombolytic therapy for pts w/:
-ART thrombosis, Graft Failures, Prosthetic ♡ valves, AF, pts w/ cerebrovascular disease
3. Aspirin: ↓ platelet aggregation, thus ↓ risk of thrombus formation
4. Trental: ↓ Bl viscosity & inhibits platelet aggregation. ↑ flexibility of RBCs to pass thru a stenotic region w/in a lumen
5. Antihypertensive drugs: ↓ Po (force) exerted on endothelial cells of vessel wall
Peripheral Art: Treatment Surgical Therapy-Thrombectomy/Embolectomy
-Removal of a thrombus or embolus fr an ART or graft
-A Fogarty catheter is inserted→the ART & passed beyond the clot. A balloon in inflated & w/drawn. Thromboembolism is removed as the balloon is w/drawn
Peripheral Art: Treatment Surgical Therapy-Endarterectomy
-ART is exposed & surgically opened in the region of Atherosclerotic disease
-The Intima, Media & Plaque are surgically removed
Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Prosthetic)
-Refers to synthetic grafts:
-Dacron, PTFE, Goretex
-Used in the Pelvis, Thigh & Above knee
Peripheral Art: Treatment Surgical Therapy-Bypass Graft (In Situ Saphenous)
-Uses the GSV left 'in place'
-Perforating vns are ligated & cut & a valve cutter (valulatome) is used to excise valves in the GSV
-The vn is anastamosed to the CFA or FEM Art & attached to an ART DIST to the obstruction
-Often used for limb salvage or to relieve Ischemic conditions in the legs & feet (Ischemic Rest Pain)
Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Reversed Saphenous)
-GSV is removed after perforating vns, tributaries & branches are ligated & cut
-Vn is 'Reversed' & surgically implanted→CFA & to an ART DIST to the occlusion
-Often used for limb salvage or to relieve Ischemic conditions in legs/feet (Ischemic Rest Pain, Gangrene, Ulceration)
-Superficial vns in arm can also be used in the LE for Autogenous conduit material
Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Non-reversed Translocated Saphenous)
-GSV is removed & relocated to another location, but is NOT reversed
-ALL valves must be removed
-Cryopreserved Grafts: ART fr Cadavers
Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Types of Anastamoses)
1. End-to-side
2. End-to-end
3. Side-to-side
Peripheral Art: Treatment Surgical Therapy-Amputation/Fasciotomy
-Amputation:
-For limb Ischemia when grafts are unsuccessful
-Fasciotomy:
-Incision & opening of a fascial compartment to relieve Po in cases of Compartment Syndrome
Peripheral Art: Treatment Surgical Therapy-
Split-thickness Skin Grafts (STSG)
-Performed after excision of burn inj
-Healthy epidermis & part of dermis removed fr ABD, Buttocks or Thigh of donor; grafted to burn site
-High Graft success rate
-Poor cosmetic success compared to full thickness skin grafts
Peripheral Art: Treatment Surgical Therapy-Endovascular (PTA)
-Percutaneous Transluminal Angioplasty
-Used for focal lesions in large vessels such as the Iliac A, Fem A & POP A
-A balloon tipped catheter is inserted→the area of narrowing
-Balloon is inflated crushing/pushing the plaque against vessel walls to ↑ lumen diameter
-An Intravascular STENT may be used together w/ balloon angioplasty
a. Inflation of balloon dilates ART & expands the stent. Balloon is deflated & w/drawn leaving Stent expanded & attached to the wall
Peripheral Art: Treatment Surgical Therapy-Endovascular (Endograft)
-Used for AO & Aortoiliac Aneurysm repair
-Uses a combo of Intravascular Stenting & Prosthetic graft technology
-Stent acts as the anchoring component & support for body of the graft
-Once graft is in position, Bl will flow only thru the graft avoiding Native ART, thus excluding the aneurysm
Peripheral Art: Treatment Surgical Therapy-Endovascular (Atherectomy)
-A catheter w/ a rotational device cuts & pulverizes the plaque where it's stored in a collecting chamber
-Disadvantages:
-Heat is generated fr rotational device
-Vessel is susceptible to puncture
Peripheral Art: Treatment Surgical Therapy-Endovascular (Compression Therapy for Pseudoaneurysm)
-Appropriateness is dependent on Size, Location & Relation of the comm channel to the Native ART
-Using sonographic guidance, Pseudoaneurysm is compressed w/ Tx to stop flow out of the ART
-Hold for 10 mins, Rest & Cont for 10 mins
-Check flow to rest of the limbs
-Procedure may take up to 45-60 mins
-Surgical intervention may be necessary if compression is unsuccessful in stopping flow
Peripheral Art: Treatment Surgical Therapy-Endovascular (Thrombin Injection for Pseudoaneurysm)
-Thrombin inj has replaced compression obliteration in many facilities
-Under U/S guidance, thrombin is injected dir→the pseudoaneurysm. Thrombus formation is almost immediate
-Risk incl thrombin leaking→ART & causing ART thrombosis w/c can lead to Emboli, Stenosis or Occlusion