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