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
<span style="text-decoration:underline;">-Arterioles:</span>
-Smallest Art vessel. Consists of Intima &amp; Media
<span style="text-decoration:underline;">-Capillaries:</span> 
-Microscopic branches of the smallest Arterioles. Consists of the Intima
-Supplies O<sub>2</sub> &amp; nutrients to Tissue &amp; remove waste products

Peripheral Arterial-Anatomy ABD AO
-Located LT of midline &amp; 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 &gt;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 &amp; Bif →Radial/Ulnar

Peripheral Arterial-Anatomy UE
<span style="text-decoration:underline;"><strong>-Subc Art:</strong></span>
-<span style="text-decoration:underline;">Rt</span> Subc Art=originates fr <span style="text-decoration:underline;">Innominate</span> (Brachiocephalic art)
-<span style="text-decoration:underline;">Lt</span> Subc Art=originates fr <span style="text-decoration:underline;">AO Arch</span>
-Both are located <span style="text-decoration:underline;">POST</span> to clavicle &amp; course betw <span style="text-decoration:underline;">ANT</span> middle scalene muscle &amp; 1st rib
<span style="text-decoration:underline;">-Divided into 3 segments:</span>
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 &amp; 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 &amp; extending to the bend of the elbow
-Initially lies MEDIAL to the humerus &amp; courses ANT to the Antecubital fossa where it BIF→RADIAL &amp; ULNART A

Peripheral Arterial-Anatomy (Radial A)
-Smallest of the Brachial A terminal branches
-Originates @ the Antecubital fossa &amp; 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 &amp; 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 &amp; crosses over the LT Iliac Vns
-CIA bif into Internal/External Iliac Art

LE Plantar Arch
<answer>
<span style="text-decoration:underline;"><strong>Anterior Tibial Art
</strong></span>↳Dorsalis Pedis Art (DPA) major branch is Deep Plantar Art (dpa)

<span style="text-decoration:underline;"><strong>Post Tibial Art
</strong></span>↳2 major distal branches: 
Lateral plantar art w/c unites w/ Deep Plantar art to form the Plantar arch
</answer>

Peripheral Arterial Anatomy-LE (CIA)
-CIA: Originates @ level of 4th Lumbar Vertebra fr BIF of Distal ABD AO
-RT CIA: Is longer than LT &amp; crosses ANT to LT Iliac Vn
-They branch→IIA &amp; EIA @ the Lumbosacral junction

Peripheral Arterial Anatomy-LE (IIA)
-aka Hypogastric A
-Originates @ the BIF of CIA (EIA origin)
-Supplies Bl to walls &amp; viscera of the pelvis, buttock, genitals &amp; 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
<span style="text-decoration:underline;">-Has 2 Dorsal branches:</span>
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 &amp; divides→DFA &amp; SFA

Peripheral Arterial Anatomy-LE (DFA) or Profunda Femoris A
-Originates @ BIF of CFA
-Courses POSTEROLATERAL @ its origin &amp; cont MEDIAL to femur where it terminates in DIST 3rd of the thigh as Perforating ART
-Supplies Bl→Thigh muscles: Adductor, Extensor &amp; Flexor muscles
-Comm. PROX w/ CFA &amp; 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 <span style="text-decoration:underline;">Genicular Art</span> (an important collateral pathway) &amp; 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 &amp; terminates @ the Popliteus muscle, dividing into ATA &amp; 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 &amp; 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 &amp; portions of the foot
<span style="text-decoration:underline;">-DPA:</span> Originates as terminal portion of the ATA on dorsum of the foot &amp; 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 &amp; PERO Art

Peripheral Arterial Anatomy-LE (PTA)
-A Branch of the Tibioperoneal trunk
-Courses POST to the Tibia, behind Medial Malleolus
-Terminates→MEDIAL &amp; 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 &amp; 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 &amp; distribution of atherosclerotic disease
a. Contributes to hardening of ART wall &amp; loss of elasticity=ART incompressible
b. Referred to as Medial Calcinosis
-Leads to small vessel disease of lower leg
-Can lead→gangrene &amp; necrosis=amputation
-Can lead→trauma due to neuropathy

Peripheral Art-Controllable Risk Factors (HYPERTENSION) HTN/HYPERLIPIDIMIA
<span style="text-decoration:underline;"><strong>-HTN:</strong></span>
-High BP
-Assoc w/ development of Atherosclerosis, HTN causes ↑ in Intraluminal ART wall stress
<strong><span style="text-decoration:underline;">-HYPERLIPIDIMIA:</span></strong>
-↑ 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 &amp; Capillaries
2. ↑ BP
3. ↑ Myocardial Oxygen demand
4. ↑ Platelet aggregation
5. ↑ Cholesterol levels

Peripheral Art-<span style="text-decoration:underline;">Uncontrollable </span>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 &amp; 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 &amp; progresses outward
-Known as <em>'pulseless'</em> 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 &amp; 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 A<em>rteritis</em> affecting DIST ART of hands &amp; feet
-Assoc w/ heavy cigarette smoking in Men &lt;40 y/o
-Rest Pain &amp; Ischemic ulcers occur early
-Assoc w/ collagen vascular syndromes such as rheumatoid arthritis &amp; 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
<answer>
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

<span style="background-color:#ffff00;">*PRIMARY</span>=Vasospasm w/ <span style="background-color:#ffff00;">NO</span> underlying dis
*<span style="background-color:#3366ff;">SECONDARY</span>=Vasospasm <span style="background-color:#3366ff;">SECONDARY</span> to underlying disease
</answer>

Peripheral Art-Mechanisms of Disease (Non-Atherosclerotic Lesions) Vasospastic Disorder=COARCTATION OF THE AO
-Congenital narrowing of AO Arch or Thoracic AO
<span style="text-decoration:underline;">-Clinical findings:</span>
-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 &amp; 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 &amp; MED to knee joint)
-Common in pts w/ severe degenerative joint disease or rheumatiod arthritis
-Large cysts are prone to rupture causing pain, tenderness &amp; swelling of calf

Peripheral Art-Signs &amp; Sx: Chronic Occlusive Disease (Claudication)
<answer>
-Claudication of LE: Progressive, reproducible, muscular pain in THIGH, BUTTOCK, or CALF after exercise
-Caused by ↓ Bl perfusion to muscle tissue during exertion &amp; is relieved by stopping the exercise
-Sx: Pain, cramping, fatigue or tightness of the leg
-Usually PROX to location of sx
-1. BUTTOCK &amp;/or THIGH pain=Aortoiliac Occlusive Disease if BILAT; PROX FEM
-2. THIGH pain=DIST EIA &amp;/or CFA disease
-3. CALF  pain=SFA &amp;/or POP A disease

<span style="background-color:#ffff00;"><strong>**Vascular Claudication is:</strong> Pain w/ exercise for a predictable distance, Relieved by rest &amp; ALWAYS reproducible</span>
</answer>

Peripheral Art-Signs &amp; Sx: Chronic Occlusive Disease (PSEUDOCLAUDICATION)
-Leg w/ exercise <span style="text-decoration:underline;">NOT</span> due to Vascular obstruction but <em>may</em> 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 &amp; Sx: Chronic Occlusive Disease (Ischemic Rest Pain)
-Persistent pain in feet &amp; toes due to ↓ Bl perfusion
-Occurs while sleeping when BP is LOW &amp; limb is Elevated
-Indicates ADV Art Occlusive Disease
-Relief: Place foot in a dependent position to ↑ Gravitational &amp; Hydrostatic Po

Peripheral Art-Signs &amp; Sx: Chronic Occlusive Disease (Tissue Loss)
-Gangrene &amp; 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 &amp; painful
-Revascularization or amputation is usually required
-Look @ ART &amp; VENOUS Ulcers for differentiation

Peripheral Art-Signs &amp; 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 &amp; Sx: Vasospastic Disorders
<answer>
-Abnormal Vasospasm of digital Art in hands or feet induced by exposure to cold
<span style="text-decoration:underline;">-Sx:</span> 
-1. Pain
-2. Paresthesia
-3. Skin color changes
-Pallor: White
-Cyanosis: Blue
-Rubor: Red

<span style="background-color:#ffff00;"><em>*MOST common digital cold sensitivity condition is Raynaud's Syndrome</em></span>
</answer>

<question>
Peripheral Art-Signs &amp; Sx: Physical Examination
(Skin Dermal Changes &amp; Temperature)
</question>
<answer>
<span style="text-decoration:underline;">-Color:</span>
-Pallor: deficient Bl supply when legs are elevated
-Rubor: Vasodilation when legs are in a dependent position (aka Dependent Rubor) &amp; Bl pools→Arterioles due to gravity
-Cyanosis: Fr Deoxygenated Bl

<em><span style="text-decoration:underline;">-Temperature: Warm vs. Cold</span></em>
-Symmetrical coolness=Vasoconstriction
-Asymmetrical coolness=ART insufficiency in leg that is cool
</answer>

Peripheral Art-Signs &amp; Sx: Physical Examination (Capillary Filling &amp; Trophic Changes)
<strong><span style="text-decoration:underline;">-Capillary filling:</span></strong> An ↑ in Capillary refill time indicates ↓ ART perfusion
<strong><span style="text-decoration:underline;">-Trophic Changes:</span></strong> Indicates poor tissue nutrition fr ART insufficiency
-Hair loss over toes &amp; dorsum of foot
-Thin, shiny, smooth or scaly skin
-Thickened, brittle toenails

Peripheral Art-Signs &amp; Sx: Physical Examination (Palpation of pulses)
-Evaluates for Pulses &amp; Aneurysms
-Eval presence, strength &amp; regularity of puls
<span style="text-decoration:underline;">-Locations for <span style="background-color:#3366ff;">LE:</span></span>
-AO, Groin (CFA), POP FOSSA (POP A), Foot (PTA &amp; DPA)
<span style="text-decoration:underline;">-Locations for <span style="background-color:#ffff00;">UE:</span> </span>
-CCA, AXILLARY A, BRACHIAL A, RADIAL/ULNAR A
<span style="text-decoration:underline;">-Rate of Pulses:</span>
-0= NONE  1+=Weak  2+=NORMAL 
-3+=Strong   4+=Bounding
-May also Indicate Aneyrysmal

Peripheral Art-Signs &amp; Sx: Physical Examination (Auscultation of Pulses)
-Using a Stethoscope, eval for Presence, Duration &amp; Strength of BRUIT
-BRUIT: 'Noise' indicates TURBULENT Bl flow caused by Stenosis w/in the Art
-It is a vibration transmitted to surrounding tissue &amp; is caused by flow disturbances in the vessel. 
-'Vibrations' or 'Thrills' may be due to a <em>Fistula, Poststenotic Turbulence or a Dialysis graft</em>
<strong>-Locations for LE:</strong> ABD AO, CFA, POP A
<strong>-Locations for UE:</strong> ♡, CCA, Subc A

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po Meas
-(UE/LE)
<span style="text-decoration:underline;">-1. RATIONALE:</span> Provides physiologic info &amp; confirm vascular etiology for <em>Claudication</em> &amp; <em>Ischemic Rest Pain
</em><span style="text-decoration:underline;">2. CAPABILITIES: </span>
-Screens for presence, level &amp; severity of Atherosclerotic Occlusive Disease
-Provides Info for baseline &amp; 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 &lt;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 &amp; bandages limit placement of cuffs &amp; PPG sensor for digital Po

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po 
-Cuff Sizes-
</question>
-S/b 20% wider than diameter of limb for accurate Po recording
-Should fit snugly, but not tight
<em>-Small cuff=Falsely elevated BP</em>
<em>-Large cuff=Falsely ↓ BP</em>

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po 
-3 Cuff  vs. 4 Cuff Technique-
</question>
<span style="text-decoration:underline;"><strong>-3 Cuff:</strong></span>
-1 large cuff on THIGH (17-22 cm)
-1 cuff on the CALF (12 cm)
-1 cuff on ANKLE (10 cm)
<span style="text-decoration:underline;"><strong>
-4 Cuff:
</strong></span>-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

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po 
-ADV &amp; DISADV-
</question>
<strong>-4 cuff:</strong> useful in diff Inflow fr FEM Art disease. HI THIGH cuff Po artifact may occur
-<span style="text-decoration:underline;">Cuff artifact:</span> Falsely ↑ HI THIGH Po 20-30 mmHg &gt; Brachial Po
-3 cuff: Uses 1 large cuff on the THIGH
-NO artifact produced
-Can NOT diff betw Inflow &amp; FEM Art disease

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po  
-Exam Protocols-
</question>
<span style="text-decoration:underline;"><strong>-Positioning:</strong></span>
-UE: Supine w/ arms @ pts sides
-LE: Supine w/ legs @ same level as ♡
<strong><span style="text-decoration:underline;">-UE</span></strong>
-12x40cm cuff: Brachial
-10x40cm cuff: Forearm &amp; Wrist
-Obtain Po Bilat fr upper arm w/ CWD on Brachial Art. Radial/Ulnar used to obtain Po fr forearm
<span style="text-decoration:underline;"><strong>-LE</strong></span>
-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 &amp; Po are taken, Art w/ highest reading will be used in obtaining rest of the Po

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po 
-Interpretation of Po in UE-
</question>
-DIFF of 20 mmHg or more betw Brachial Po=<em>Innominate, Subc, Axillary or PROX BA Occlusive disease on the side of the ↓ Po
-</em>Po fr wrist &amp; forearm s/b ≥ Brachial Po
-↓ in Po of &gt;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

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po 
-Interpretation of Po in LE-
</question>
-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 &gt; Brachial Po
-Low HI THIGH Po=Inflow Disease
-Diff betw segments (or BP cuffs) &amp; limb to limb Po=20 mmHg or &lt; to be NORMAL

ABI Interpretation Criteria
<strong>1.0 but &lt;1.4:</strong> Normal (&gt;1.4=Art Medial Ca++)
<strong>0.9-1.0:</strong> Minimal Art Disease
<strong>0.5-0.9:</strong> Claudication (Single level disease)
<strong>0.3-0.5:</strong> Ischemic Rest Pain (Multi level dis)
<strong>&lt;0.3:</strong> Tissue loss/gangrene

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Digital Po <span style="text-decoration:underline;">Positioning</span>-
-Fingers: Pt can sit w/ arms @ sides &amp; 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 <span style="text-decoration:underline;">Technique</span>-
-Waveforms can be obtained using CWD or PPG 
-Toe cuffs s/b @ least 1.2x of the toe girth &amp; first obtain ABI to r/o PROX disease
-Finger cuff size= 2 - 2.5 cm
-<em>Disease w/ specific testing:</em> <span style="text-decoration:underline;">Fingers w/ cold stress for Raynauds:</span>
1. Hands are immersed in ice water for 3 mins
2. Waveforms &amp; Po taken immed upon removal fr immersion &amp; @ 5 mins post stress

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Digital Po <span style="text-decoration:underline;">Interpretation</span>-
-Toe Po &amp; TBI are useful in assessing small vessel disease in toes/foot
-Used when ABI canNOT be used due to Ca+ art
-<strong>TBI: Highest Brachial Po ÷ Toe Po</strong>
-<strong>TBI &gt;0.66 or 0.7=NORMAL</strong>; <em>&lt;0.66: Abnormal</em>
-<strong>FBI: 0.8-0.9=NORMAL</strong>; Finger Po may be ↓ if digits are Cold

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <em>-Constant-load Treadmill Exercise Testing-</em>
-Performed on pts that present w/ Claudication &amp; has a normal @ rest Physiologic study
-Test is performed to reproduce pts Sx
-Exercise should induce Peripheral <span style="text-decoration:underline;">Vasodilatation</span>in the microcirculation so DIST peripheral R ↓ &amp; flow ↑

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Constant-load Treadmill Exercise Testing- <span style="text-decoration:underline;">Limitations</span>
-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 &lt;0.3
-Acute DVT
-Ulceration or gangrene

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Constant-load Treadmill Exercise Testing-<span style="text-decoration:underline;">Protocol</span>
-Place BP cuffs (upper arm &amp; both ankles)
-Pt walks @ 1.5-2 mph w/ 10-12<sup>o</sup> 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 &amp; arm &amp; 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-<span style="text-decoration:underline;">Interpretation Post Exercise</span>
<strong>-NORMAL:</strong> Ankle Po ↑ slightly post-exercise or ↓ slightly but return to resting Po w/in 1 min
<strong>-ABNORMAL:</strong> ankle Po ↓ Post-exercise
<span style="text-decoration:underline;">-Single level disease:</span> ABIs ret back to normal w/in <strong>2-6</strong> mins
-<span style="text-decoration:underline;">Multi-level disease:</span> ABIs remain ↓ for <strong>12</strong> or more mins
-Post exercise Po &lt;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 &amp; Ischemia

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia- <span style="text-decoration:underline;">Capabilities &amp; Limitations</span>
<span style="text-decoration:underline;">-Capabilities:
</span>-Docs effects of Occlusive disease in pts who are unable to move at the time of exam
<span style="text-decoration:underline;">-Limitations:</span>
-Poor pt tolerance due to PAIN
-Does NOT simulate walking

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia- <span style="text-decoration:underline;">Exam Protocol</span>
-Cuff placed around Low thigh &amp; inflated to suprasystolic Po (20-30 mmHg above ↑est Brachial BP)
-Maintain Po for 3-5 mins to produce Ischemia &amp; Vasodilatation DIST to the cuff
-Immed upon rapid deflation of cuff, obtain Brachial &amp; Ankle Po

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Reactive Hyperemia- <span style="text-decoration:underline;">Interpretation</span>
<span style="text-decoration:underline;">-NORMAL:</span>
-Mild drop in ankle Po 17-34%
<span style="text-decoration:underline;">-ABNORMAL:</span>
-<strong>Single level:</strong> approx 50% drop in ankle Po
-<strong>Multi level:</strong> &gt;50% drop in ankle Po

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Toe Raises &amp; Limitation-
-May be substituted for Treadmill &amp; Reactive Hyperemia in SYMPTOMATIC pts that can NOT move due to ♡ condition, COPD, etc
-Limitation:
-Does <span style="text-decoration:underline;">NOT</span> reproduce <em>Sx of Claudication</em> nor does it use same muscles as walking does
-Symptomatic calf pain after toe raises may be due solely to <em>Fatigue</em>

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 &amp; onset of pain
-Immed after exercise, obtain Po fr Arm &amp; Ankle

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <span style="text-decoration:underline;">-PVR &amp; Capabilities-</span>
-aka Pneumo or Air Plethysmography
-Records Vol changes in a limb related to Pulsatile Art flow
<strong><span style="text-decoration:underline;">-Capabilities:</span></strong>
-Assesses overall flow to limb segment
-Not affected by Ca+ Art

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <span style="text-decoration:underline;">-PVR &amp; Limitations-</span>
-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 &amp; Collateral branches
-Obesity &amp; Edema = False + results
-Waveforms affected by room temp, basal state &amp; medications
-Digits w/ Po &lt;20 mmHg may NOT generate a waveform
-Pt w/ resting muscle tremors=Waveform artifacts

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <span style="text-decoration:underline;">-PVR- Pt Positioning &amp; Protocol</span>
-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 &amp; 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 &amp; Interpretation of Waveforms-
-Combo of <span style="text-decoration:underline;"><em>Qualitative</em></span> &amp; <em><span style="text-decoration:underline;">Quantitative</span> </em>assessment
-Both AMP &amp; Contour of waveform is considered
-<img data-image_id="0734ac7a-f361-4859-9f5b-2c35f414b157" 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" >

<img data-image_id="0734ac7a-f361-4859-9f5b-2c35f414b157" 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oJr8eZ7AB3OKbv8A2Sr90m7/ANkq/dIOTPVgE7kGri0ouerVbvITdsbXBszXwX2GRth37L9q49IfslX7pcGu/Zav3R+9BsNdRt1mrg94PvXDK2CRwawvfc2uI3Ed9rLbA+OWFksfqvaHNNrGxW6yAi4AXKAiIgIiICirfyzDx/rO/lvVqirfy7D/AK538tyC0rq87cQ0dTG3dO5nztlEgDszRpLOYB62UgB3JYuGoWXZyF83Fq92HxxvZHnbmzS6icsYIzHVyXugikrsRe17XwPDHXa8ticTEeHsG12xmsbL36sKeqxMRRRtY9ha2Fh0lO9xsct3E3tsLrjaCNduPe3F3x1dRDLTPkDZ8kLo8oBHA1G5HG/bs+F+P+IIdAZdzzcEEPF23a4Nc6222xh17L9tgmkr8WdJmigmOR7rNMBaH8B1gdWzM0bCdu3WFmKusimfVO0kjTCwgGJ0YeNI7ggOtZ+UjVqJNtS3zY8INKH0NR8jfPrYdjA/l+ie/V0rN2ItmrIoGRjgVAaS4BwItJrbr1G7D1bNtwA+pDn0TNLYvsM1tl1pl+dqX6mX7WKoBSyN/wCaU55IpPtYgrREQEREBERAREQFPR+o/wCtf/EVQpqU2jlJ2aV9/EUFBXw5cTlpa2YVF3RXIhy5Sw8Jo1na0gnXfVbWNlltbjUD4YZgx4ZLO+J1/WZla43sLk3DQR0EFbDX4bpZBniLiOFZhJeNWoauFfM3ZfaOUIJ5MaMUb3TUxaWQ6YjSBwy6769hs4AHXqBBWHp54e+OSlDHMEd7zNIu97mt1gfqE36QLXuBWMSw8WYJAWloAAjcRY7Bs6Dq29yNr8MkhzNcx0RytvozaxsW8Ww31cWtBdBIZYWSObkc9oJbe9u1bXeqepfJixiHIzSRljnkNDGAvIJe5o2DZwTrVsFVDUMzwPzDKDe1hYi4+CBh3zbS/Us+wKpS4d820v1LPsCqQEREBERAREQFFWC9bh/RM7+W5WrRNTxT5RNGH5Tdt+I2t/UoN60Pgikc9z4mFz25HEtBzN5D0aytfo6j5hveU9HUfMN7yg53DSXd/loddr8Aa7Wt9g7guNwUmw0kFspb+LGw7R1ayno6j5hveU9HUfMN7yg5dRUrs2amgObbeMG+q32aupGUdKyTOymhY++bMGAG+vXs6T3rj0dR8w3vKejqPmG95QVhSv8AnSD6mT+Ji49HUfMN7ysoaSCCTPFE1jrWuOT+wEFKIiAiIgIiICIiAoIY900dRC5zmB8srSWmxtmI1K9RnD6Ylz8jgXEuNpHAE9hQTnCaXTPkZnjLnh/AdYNcGllwNnqmxWBwSjzBwY9pb6uVxGT1bW6jG23/AOlV+jaT6Mnvn/eufR1N9GX3z/vQaWYVTs9XOOEx3rX1tJI+JN+VavQdFkbGNKGNDQBpDsa0AfAD+yVYMPpvoye9d9653BTfRf7x33oJfRFO1zXsMgcwgtOc7Q4uF+1x7NS3UdMKOmLODmc50jy0EAuJubC5sO1Z7gpvou94770NDTO1Fh8bvvQMO+baX6ln2BVLWxjY2NYxuVrQAANgC2ICIiAiIgIiICIiAiIgIiICIiAiIgIiICIiAiIgIiICIiAiIgIiICIiAiIgIiICIiD/2Q==" >
-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 &amp; a reduced rise time in systole
-SEVERELY Abnormal: Very LOW AMP &amp; broadening of wave contour or flat line

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG-
-Detects &amp; Records Cutaneous Pulses using Infrared light-emitting diode (sensor)
-Light is transmitted→capillary beds(microcirculation) &amp; portion of it is reflected back to a photosensor
-Waveform represents flow present in microcirculation

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <span style="text-decoration:underline;">-PPG</span> <span style="text-decoration:underline;">Uses &amp; Capabilities</span>-
<span style="text-decoration:underline;"><strong>-Uses:</strong></span>
-Evaluates ART disease w/in the digits
-Can be used to assess skin perfusion (wound healing potential) &amp; for digital cold sensitivity testing
<strong><span style="text-decoration:underline;">-Capabilities:</span></strong>
-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-
-<span style="text-decoration:underline;">Qualitative</span> assessment only
-Significant PROX Art dis reduces digital perfusion &amp; eliminates ability to eval small vessel art in digits
-Vasoconstriction affects Quality of exam (Hands/feet must be warm &amp; calm)
-Incorr application or poor skin contact of sensor=Artifact &amp; poor quality
-Digital Po &lt;20 mmHg may NOT generate a waveform

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Protocol- <span style="text-decoration:underline;"><em>Toe/Finger Testing</em></span>
-Supine or sitting w/ arms @ side &amp; 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 &amp; document Po when waveform reappears

<question>
Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -PPG Protocol- 
<span style="text-decoration:underline;">Cold Immersion Stress Test</span>
</question>
-This Test documents results in response to Cold Exposure
-Record Resting waveform using PPG sensor applied underneath ea finger
-Immerse hands in ICE cold H<sub>2</sub>O for 3 mins
-Immed obtain waveforms &amp; then 5 mins after immersion

Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <span style="text-decoration:underline;">-PPG Interpretation of Waveforms-</span>
-Normal to Severely abnormal same as PVR analysis
-Peaked Pulse Contour: Assoc w/ Digital Vasospasm=Pointed peaked waveform w/ an anacrotic notch on upslope &amp; DN high on downslope
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Peripheral Art: Non-Invasive Test Procedures <span style="text-decoration:underline;">(DIRECT Testing)</span> -CWD Capabilites/Limitations-
<strong><span style="text-decoration:underline;">-Capabilities:</span></strong>
-Effective &amp; simple screening test for presence of PVD esp Atherosclerotic Occlusive Dis
<strong><span style="text-decoration:underline;">-Limitations:</span></strong>
-Requires skill &amp; experience
-Doppler may be attenuated by scar tissue, hematoma or Ca+ plaque in the Art
-Dampened waveforms seen in CHF
-<em>MAJOR Limitation:</em> Inability to localize specific segment of disease

<question>
Peripheral Art: Non-Invasive Test Procedures 
(<span style="text-decoration:underline;">DIRECT Testing</span>) -CWD Analog vs CWD-
</question>
-Analog Doppler uses a <em>Zero-crossing F</em> 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 <span style="text-decoration:underline;">(DIRECT Testing)</span> -<em>CWD <strong>Qualitative</strong> Interpretation-</em>
<span style="text-decoration:underline;"><strong>-Qualitative Interpretation:</strong></span>
<strong>-Normal:</strong> HI Resistant waveform (triphasic)
-Rapid Systolic upstroke, early diastolic reversal &amp; late diastolic oscillaiton
<strong>-Abnormal:</strong> Monophasic, Non-pulsatile, or Absent as disease progresses
-Loss of Reverse component 
-<span style="text-decoration:underline;">@ the site of Stenosis</span>, V ↑ in pitch &amp; Amp
-<span style="text-decoration:underline;">DIST to a HDS Stenosis</span>=Dampened signal w/ LESS prominent Systolic component w/ absence of diastolic sounds
<span style="background-color:#ffff00;">**DIASTOLIC component tells what is happening DISTAL to the sample</span>
<span style="background-color:#ffff00;">DDDs=Decreased Diastole, DIST to Disease
</span>

Peripheral Art: Non-Invasive Test Procedures <span style="text-decoration:underline;">(DIRECT Testing)</span> -CWD <strong>Quantitative</strong> Interpretation- PI
<answer>
<img data-image_id="3fdaafd9-cf7f-4c3e-b46d-e5b1ac34e9f4" 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" width="241" height="37" >

-Diff Inflow fr Outflow disease
-Can be obtained fr Analog or Spectral Waveforms (Spectral Analysis is MORE sensitive than Analog waveforms) 
<span style="text-decoration:underline;">-Normal values:</span> usually ↑ fr Central to Peripheral Vessels
-CFA: &gt;5.5
-POP A: 8
-PTA: 14 
Abnormal Values:
-CFA: &lt;5
-In the absence of SFA disease, PI of &lt;5=Aorto-Iliac disease

<span style="background-color:#ffff00;">**There is an <span style="text-decoration:underline;"><em>INVERSE</em></span> Rel betw Art disease &amp; PI: If <span style="text-decoration:underline;">NO</span> Art dis present=PI is HIGH</span>
<span style="background-color:#ffff00;">As the severity of ART dis ↑, PI ↓</span>
</answer>

Peripheral Art: Non-Invasive Test Procedures <span style="text-decoration:underline;">(DIRECT Testing) </span>-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 <span style="text-decoration:underline;">(DIRECT Testing)</span> -Duplex/Color Flow Imaging- <strong><em>Capabilities</em></strong>
-Ability to indicate Exact location of disease &amp; determine if a segment is stenosed or totally occluded
-Detects/Diff Aneurysms, Pseudoaneurysms, Hematoma, AV fistulae, Graft patency
-IDs Collaterals
-FF up &amp; monitor disease progression, medical therapy, surgical and/or interventional procedures

Peripheral Art: Non-Invasive Test Procedures <span style="text-decoration:underline;">(DIRECT Testing)</span> -Duplex/Color Flow Imaging- <em><strong>Limitations</strong></em>
-Time consuming
-Requires skill &amp; experience
-Pt body habitus=obesity &amp; 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- <em><strong>Pt Positioning</strong></em>
-UE: Supine w/ arms relaxed @ side
-LE: Supine. Hips externally rotated w/ knee slightly bent
-Use <strong>5, 7.5</strong> or <strong>10 MHz Linear Tx</strong> for <em>FEM, POP, TIBIAL ARTS or SUBC/Brachial Art)</em>
-Use <strong>2.0-3.5 MHz Phased Array Tx</strong> for <em>Deep vessels (ie AO, Iliac Art)</em>

Peripheral Art: Non-Invasive Test Procedures <span style="text-decoration:underline;">(DIRECT Testing)</span> -Duplex/Color Flow Imaging- <em><strong>Protocol LE</strong></em>
-Eval (w/ 2-D in SAG &amp; TRV, Color &amp; Spectral Doppler) ff ART for presence, location, size &amp; characteristics of plaque &amp;/or thrombus:
-DIST EIA
-CFA
-DFA or Profunda Femoris
-SFA
-POP A
-Tibioperoneal Trunk
-ATA
-PTA
-PERO A

Peripheral Art: Non-Invasive Test Procedures <span style="text-decoration:underline;">(DIRECT Testing) </span>-Duplex/Color Flow Imaging- <em><strong>Protocol UE</strong></em>
-Eval (w/ 2-D in SAG &amp; TRV, Color &amp; Spectral Doppler) ff ART for <em>presence, location, size &amp; characteristics of plaque &amp;/or thrombus:
-</em>SUBC A
-AXILLARY A
-BRACHIAL A
-RADIAL/ULNAR A

<question>
Peripheral Art: Non-Invasive Test Procedures
(<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Imaging &amp; Spectral doppler technique</span>
</question>
-Assess w/ Color Doppler &amp; 'mapping' regions of flow disturbances w/ Spectral Doppler
-If Stenosis is seen w/ B-Mode &amp;/or Color Doppler, obtain Spectral Waveforms fr:
-PRE Stenotic, MAX Stenotic, &amp; POST Stenotic regions
-Meas PSV fr various regions

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">2D Interpretation</span>
<strong><span style="text-decoration:underline;">-Normal:</span></strong>
-No Intraluminal echoes w/in vessel
<strong><span style="text-decoration:underline;">-Abnormal:</span></strong>
-Intraluminal echoes w/in vessel lumen
-POST Shadowing fr Ca+ Art wall
-Narrowing of vessel lumen
<span style="text-decoration:underline;"><strong>-Measurements:</strong></span>
-Diameter vs. Area
-<em>Spectral Waveform Analysis</em> is the <span style="text-decoration:underline;">PRIMARY</span> method for classifying severity of disease

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span><strong> NORMAL Flow characteristics in Native ART</strong>
<span style="text-decoration:underline;"><strong>-LE:</strong></span>
-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 (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> <strong>NORMAL Flow characteristics in Bypass Grafts/Stents</strong>
-Monophasic for 1st several weeks POST-OP (due to Vasodilatation)
-Normal Triphasic signal w/in minimal Spectral Broadening
-VEL &gt;45 cm/s obtained fr smallest diameter segment of graft

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> <strong>ABNORMAL Flow characteristics in STENOSIS</strong>
-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 &amp; Flow=HDS
<span style="background-color:#ffff00;"><em>**Bl flow becomes increasingly limited as # of Stenotic lesions ↑ w/in a vessel segment</em></span>
-Ischemia cause DIST Arterioles to remain dilated allowing more Bl flow to tissues resulting in MONOPHASIC waveform

<question>
Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> 
<strong>ABNORMAL Flow characteristics in STENOSIS Profile</strong>
</question>
<strong><span style="text-decoration:underline;">-PROX:</span></strong>
-Vel are usually Dampened
-<strong><span style="text-decoration:underline;">@ Entrance, w/in Stenosis, &amp; @ Exit of Stenosis:</span></strong>
-Vel ↑ w/ Spectral Broadening; Flow becomes Disorganized
<strong><span style="text-decoration:underline;">-DIST to Stenosis:</span></strong>
-Post Stenotic Turbulence w/ Flow reversals, flow separations, Vortices &amp; Eddy Currents

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing)-Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> <strong>ABNORMAL Flow characteristics in Collateral effects</strong>
-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 (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span><strong> LE: Abnormal PSV @ a stenosis compared to Pre-Stenotic PSV</strong>
<answer>
<span style="text-decoration:underline;">-2:1 ratio = &gt;50% DR</span>
&gt;200 cm/s = &gt;50% DR

<span style="text-decoration:underline;">-4:1 ratio = &gt;75% DR</span>
&gt;400 cm/s = &gt;75% DR
</answer>

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> <strong>ABNORMAL Flow characteristics in Occlusion</strong>
-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 (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation </span><strong>ABNORMAL Flow characteristics in Bypass grafts/stents</strong>
-Compare PRE &amp; POST stenotic VEL
-2:1 ratio = &gt; 50% DR (&gt;200 cm/s)
<strong>NOTE:</strong> <span style="background-color:#ffff00;">It is a NORMAL finding to observe retrograde flow into the bypassed segment of the Native Art due to ↓ Po</span>
-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 (<em>DIRECT </em>Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> <strong>ABNORMAL Flow characteristics in Aneurysm</strong>
-↑ in Diameter of 50% or &gt; the native Art is considered Aneurysmal
-B-mode: documents bulging Art wall &amp; obtain measurements of TL &amp; RL in both SAG &amp; TRV planes
-Color doppler: Document RL in both SAG &amp; TRV planes
-Spectral doppler waveforms obtained w/in RL to detect abnormal flow
-Most common Peripheral Art Aneurysm is in <strong>POP A</strong>; <em>POP aneurysms</em> can <em>occlude</em> vessel leading to Sx of <em>Acute Ischemia</em>

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation</span> <strong>ABNORMAL Flow characteristics in Pseudoaneurysm </strong>
-FEM Pseudoaneurysms usually occur ff <em>ART punctures fr Angiography or Angioplasty</em>
-Bypass graft anastomotic failure or rupture
<span style="text-decoration:underline;">-Color Doppler:</span> <em>'Yin-yang'</em> sign w/ possible thrombosis w/in false lumen
-<span style="text-decoration:underline;">Spectral Doppler</span> sampling=<em>to-and-fro flow</em>

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler Interpretation </span><strong>ABNORMAL Flow characteristics in a Trauma</strong>
-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 &lt;0.9

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT </em>Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler <strong>Qualitative</strong> Interpretation</span>
-Arterial flow Qualitative interpretation is described as Tri, Bi or Monophasic 
-Turbulence of flow, seen as Spectral Broadening, is usually noted in late Systole &amp; early Diastole, as the 'filling in' of the spectral window indicates disease fr mild to severe

Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) -Duplex/Color Flow- <span style="text-decoration:underline;">Spectral Doppler <strong>Quantitative</strong> Interpretation</span>
<answer>
<span style="text-decoration:underline;"><strong>-PSV:</strong></span>
-Reflects the <span style="text-decoration:underline;">MAX</span> Acceleration of flow during the <em>Cardiac cycle</em>
<span style="text-decoration:underline;"><strong>-EDV:</strong></span>
-Reflects the <span style="text-decoration:underline;">Resting</span> stage of the <em>Cardiac cycle</em>, before the onset of the next cardiac contraction
<span style="background-color:#ffff00;"><strong><span style="text-decoration:underline;">-NOTE:</span></strong> Systole=PROX disease</span>
<span style="background-color:#ffff00;">Diastole= DIST disease</span>
<span style="background-color:#ffff00;">Evaluate Systole first

</span>
</answer>

<question>
Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) Duplex/Color Flow
<span style="text-decoration:underline;">Spectral Doppler <strong>Quantitative</strong> Interpretation</span> <strong>Velocity Ratio</strong>
</question>
<answer>
-Qtfys ART disease in pts w/ multilevel disease

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" width="231" height="40" >
</answer>

<question>
Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) Duplex/Color Flow <span style="text-decoration:underline;">Spectral Doppler <strong>Quantitative</strong> Interpretation</span> 
<strong>Pulsatility Index</strong>
</question>
<answer>
-Numerical indicator of <span style="text-decoration:underline;">Distal Resistance</span>
-Used to differentiate Inflow fr Outflow disease; as severity of ART dis ↑, PI ↓


<img data-image_id="dbde0074-9085-46f7-9780-d47af1177444" src="data:image/jpeg;base64,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" width="164" height="41" >
</answer>

<question>
Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT </em>Testing) Duplex/Color Flow <span style="text-decoration:underline;">Spectral Doppler <strong>Quantitative</strong> Interpretation</span> 
<strong>Resistive Index</strong>
</question>
<answer>
-Numerical indicator of <span style="text-decoration:underline;">Resistance</span>

<img data-image_id="d42fe789-5fe1-4cb3-91c6-60f0bcebc912" src="data:image/jpeg;base64,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" width="203" height="51" >
</answer>

<question>
Peripheral Art: Non-Invasive Test Procedures (<em>DIRECT</em> Testing) Duplex/Color Flow <span style="text-decoration:underline;">Spectral Doppler <strong>Quantitative</strong> Interpretation</span> 
<strong>Acceleration Time</strong>
</question>
-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 (<em>DIRECT </em>Testing) Duplex/Color Flow <span style="text-decoration:underline;">Color Doppler Interpretation </span>
-Locates &amp; IDs presence or absence of flow w/in a vessel
-IDs Direction of flow in relation to the Tx
(<span style="text-decoration:underline; background-color:#0000ff;"><strong>B</strong></span>lue <span style="text-decoration:underline; background-color:#0000ff;"><strong>A</strong></span>way <span style="text-decoration:underline; background-color:#ff0000;"><strong>R</strong></span>ed <span style="background-color:#ff0000;"><strong><span style="text-decoration:underline;">T</span></strong></span>oward)
-<em>Qualitatively</em> assesses flow characteristics:
1. Accelerated flow
2. Turbulent flow
3. Normal Systolic &amp; Diastolic flow components in relation to Spectral Analysis

<question>
Peripheral Art: <span style="text-decoration:underline;">Correlative &amp;/or Prior Imaging</span>
<strong>Conventional Angiography</strong>
</question>
-Method: Seldinger Technique
-Thin catheter is inserted→ CFA, AXILLARY, or Brachial Art
-Contrast agent is inj thru catheter &amp; highlights ART lumen
-Images of highlighted vessels of interest are recorded

Peripheral Art: <span style="text-decoration:underline;">Correlative &amp;/or Prior Imaging</span> DSA
-Same technique used in Cerebrovascular

Peripheral Art: <span style="text-decoration:underline;">Correlative &amp;/or Prior Imaging</span> <strong>Interpretation</strong>
-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: <span style="text-decoration:underline;">Correlative &amp;/or Prior Imaging</span> <strong>Limitations</strong>
-Same as Cerebrovascular 
-Anaphylactic reaction, renal failure or hemorrhages @ the site of ART puncture are possible risks

Peripheral Art: <span style="text-decoration:underline;">Correlative &amp;/or Prior Imaging</span> <strong>CTA Computed Tomographic Angiography</strong>
-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

<question>
Peripheral Art: <span style="text-decoration:underline;">Correlative &amp;/or Prior Imaging</span>
<strong>MRA Magnetic Resonance Angiography</strong>
</question>
-Vascular imaging technique using <em>Radio waves</em> in a <em>strong magnetic field</em> to produce 2-D &amp; 3-D images of bl vessels <strong>w/o</strong> 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: <span style="text-decoration:underline;">Treatment</span> <strong>Medical Therapy</strong>
-Control or reduction of risk factors incl obesity, high cholesterol, hypertension &amp; 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 &amp; ↓ BP
4. Stop smoking: Nicotine causes Vasoconstriction &amp; irritates the endothelium

Peripheral Art: <span style="text-decoration:underline;">Treatment</span> <strong>Medical Drugs</strong>
<span style="text-decoration:underline;"><strong>-Anticoagulants:</strong></span>
1. <span style="text-decoration:underline;">Heparin or Lovenox</span> administered either thru IV or by subcutaneous inj, prevent bl coagulation &amp; prevent ext of thrombus, NOT to dissolve it
2. <span style="text-decoration:underline;">Warfarin</span> is taken orally after Heparin or thrombolytic therapy for pts w/: 
-<em>ART thrombosis, Graft Failures, Prosthetic ♡ valves, AF, pts w/ cerebrovascular disease</em>
3. <span style="text-decoration:underline;">Aspirin:</span> ↓ platelet aggregation, thus ↓ risk of thrombus formation
4. <span style="text-decoration:underline;">Trental:</span> ↓ Bl viscosity &amp; inhibits platelet aggregation. ↑ flexibility of RBCs to pass thru a stenotic region w/in a lumen
5. <span style="text-decoration:underline;">Antihypertensive drugs:</span> ↓ Po (force) exerted on endothelial cells of vessel wall

Peripheral Art: <span style="text-decoration:underline;">Treatment</span> <strong>Surgical Therapy-Thrombectomy/Embolectomy</strong>
-Removal of a thrombus or embolus fr an ART or graft
-A Fogarty catheter is inserted→the ART &amp; passed beyond the clot. A balloon in inflated &amp; w/drawn. Thromboembolism is removed as the balloon is w/drawn

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endarterectomy</strong>
-ART is exposed &amp; surgically opened in the region of Atherosclerotic disease
-The Intima, Media &amp; Plaque are surgically removed

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Bypass Graft (Prosthetic)</strong>
<span style="text-decoration:underline;">-Refers to synthetic grafts:</span>
-<em>Dacron, PTFE, Goretex</em>
-Used in the Pelvis, Thigh &amp; Above knee

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Bypass Graft (In Situ Saphenous)</strong>
-Uses the GSV left 'in place'
-Perforating vns are ligated &amp; cut &amp; a valve cutter (valulatome) is used to excise valves in the GSV
-The vn is anastamosed to the CFA or FEM Art &amp; attached to an ART DIST to the obstruction
-Often used for limb salvage or to relieve Ischemic conditions in the legs &amp; feet (Ischemic Rest Pain)

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Bypass Graft (Reversed Saphenous)</strong>
-GSV is removed after perforating vns, tributaries &amp; branches are ligated &amp; cut
-Vn is 'Reversed' &amp; surgically implanted→CFA &amp; 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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Bypass Graft (Non-reversed Translocated Saphenous)</strong>
-GSV is removed &amp; relocated to another location, but is NOT reversed
-ALL valves must be removed
-<span style="text-decoration:underline;">Cryopreserved Grafts:</span> <em>ART fr Cadavers</em>

Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Types of Anastamoses)
1. End-to-side
2. End-to-end
3. Side-to-side

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Amputation/Fasciotomy</strong>
<span style="text-decoration:underline;">-Amputation:</span>
-For limb Ischemia when grafts are unsuccessful
<span style="text-decoration:underline;">-Fasciotomy:</span>
-Incision &amp; opening of a fascial compartment to relieve Po in cases of Compartment Syndrome

<question>
Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-
<strong>Split-thickness Skin Grafts (STSG)</strong>
</question>
-Performed after excision of burn inj
-Healthy epidermis &amp; 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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endovascular (PTA)</strong>
-Percutaneous Transluminal Angioplasty
-Used for focal lesions in large vessels such as the Iliac A, Fem A &amp; 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 &amp; expands the stent. Balloon is deflated &amp; w/drawn leaving Stent expanded &amp; attached to the wall

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endovascular (Endograft)</strong>
-Used for AO &amp; Aortoiliac Aneurysm repair
-Uses a combo of Intravascular Stenting &amp; Prosthetic graft technology
-Stent acts as the anchoring component &amp; 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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endovascular (Atherectomy)</strong>
-A catheter w/ a rotational device cuts &amp; pulverizes the plaque where it's stored in a collecting chamber
<span style="text-decoration:underline;">-Disadvantages:</span>
-Heat is generated fr rotational device
-Vessel is susceptible to puncture

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endovascular (Compression Therapy for Pseudoaneurysm)</strong>
-Appropriateness is dependent on <span style="text-decoration:underline;">Size</span>, <span style="text-decoration:underline;">Location</span> &amp; <span style="text-decoration:underline;">Relation</span> of the comm channel to the <em>Native ART</em>
-Using sonographic guidance, Pseudoaneurysm is compressed w/ Tx to stop flow out of the ART
-Hold for 10 mins, Rest &amp; Cont for 10 mins
-Check flow to rest of the limbs
-Procedure may take up to 45-60 mins
-<span style="background-color:#ffff00;"><em>Surgical intervention may be necessary if compression is unsuccessful in stopping flow</em></span>

Peripheral Art: <span style="text-decoration:underline;">Treatment Surgical Therapy-</span><strong>Endovascular (Thrombin Injection for Pseudoaneurysm)</strong>
-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 &amp; causing ART thrombosis w/c can lead to Emboli, Stenosis or Occlusion