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 & Media <span style="text-decoration:underline;">-Capillaries:</span> -Microscopic branches of the smallest Arterioles. Consists of the Intima -Supplies O<sub>2</sub> & 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 <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 & course betw <span style="text-decoration:underline;">ANT</span> middle scalene muscle & 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 & 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 <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 & 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 <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 & 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 <span style="text-decoration:underline;">Genicular Art</span> (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 <span style="text-decoration:underline;">-DPA:</span> 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 <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 & 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 & 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 <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 & 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 & 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 <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 & 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) <answer> -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 <span style="background-color:#ffff00;"><strong>**Vascular Claudication is:</strong> Pain w/ exercise for a predictable distance, Relieved by rest & ALWAYS reproducible</span> </answer> Peripheral Art-Signs & 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 & 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 <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 & Sx: Physical Examination (Skin Dermal Changes & 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) & 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 & Sx: Physical Examination (Capillary Filling & 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 & 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 <span style="text-decoration:underline;">-Locations for <span style="background-color:#3366ff;">LE:</span></span> -AO, Groin (CFA), POP FOSSA (POP A), Foot (PTA & 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 & 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 <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 & confirm vascular etiology for <em>Claudication</em> & <em>Ischemic Rest Pain </em><span style="text-decoration:underline;">2. CAPABILITIES: </span> -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 <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 & 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 > Brachial Po -3 cuff: Uses 1 large cuff on the THIGH -NO artifact produced -Can NOT diff betw Inflow & 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 & 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 & 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 & 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 <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 > 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 <strong>1.0 but <1.4:</strong> Normal (>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><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 & 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 & 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 & Po taken immed upon removal fr immersion & @ 5 mins post stress Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) -Digital Po <span style="text-decoration:underline;">Interpretation</span>- -Toe Po & 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 >0.66 or 0.7=NORMAL</strong>; <em><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 & 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 ↓ & 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 <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 & 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 & 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-<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 <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- <span style="text-decoration:underline;">Capabilities & 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 & 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- <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> >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 <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 & onset of pain -Immed after exercise, obtain Po fr Arm & Ankle Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) <span style="text-decoration:underline;">-PVR & 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 & 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 & 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) <span style="text-decoration:underline;">-PVR- Pt Positioning & 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 & 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 <span style="text-decoration:underline;"><em>Qualitative</em></span> & <em><span style="text-decoration:underline;">Quantitative</span> </em>assessment -Both 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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" > -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) <span style="text-decoration:underline;">-PPG</span> <span style="text-decoration:underline;">Uses & 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) & 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 & 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- <span style="text-decoration:underline;"><em>Toe/Finger Testing</em></span> -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 <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 & 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 & DN high on downslope <img data-image_id="f515216e-0270-4a95-b1c8-cf94612aa0ae" 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width="159" height="159" > 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 & simple screening test for presence of PVD esp Atherosclerotic Occlusive Dis <strong><span style="text-decoration:underline;">-Limitations:</span></strong> -Requires skill & 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 & 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 -<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: >5.5 -POP A: 8 -PTA: 14 Abnormal Values: -CFA: <5 -In the absence of SFA disease, PI of <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 & 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 & 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 <span style="text-decoration:underline;">(DIRECT Testing)</span> -Duplex/Color Flow Imaging- <em><strong>Limitations</strong></em> -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- <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 & 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 <span style="text-decoration:underline;">(DIRECT Testing) </span>-Duplex/Color Flow Imaging- <em><strong>Protocol UE</strong></em> -Eval (w/ 2-D in SAG & TRV, Color & Spectral Doppler) ff ART for <em>presence, location, size & characteristics of plaque &/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 & Spectral doppler technique</span> </question> -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 (<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 >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 & 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, & @ 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 & 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 = >50% DR</span> >200 cm/s = >50% DR <span style="text-decoration:underline;">-4:1 ratio = >75% DR</span> >400 cm/s = >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 & POST stenotic VEL -2:1 ratio = > 50% DR (>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 > 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 <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 <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 & 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 <img data-image_id="f12b2f51-42f5-409e-ab81-5c9b22495967" 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c7o/gpLOWlAC23uQyXYvM19Hpwv5r6Iz6cNoZPJlM5LQSnIaxnQwhszRpDSKfhbgOtgpUhwoiHO6/y50rhs4Ak1XmOnaVDk0TSKL/FRxk2drkNlZi8jiidC5wMriAgJx+ASaKjRb7EKrQ/TNwbNSpEgxx4ib4OxIIYfW0dlM8py/qaARTZfIILJKWiXgEERObgE/hy6k8d1F8nSH61F2/mxRYOZmb4oUKZ5nxGlY/fgF/hvRnL7ZLE3RYr8S0lwKMddENafw/09A2zTdUuUd26m++mWKFCkOAMQ53d163KBpMUnrH1VDPcrbyqGZ8W5i7h/R+kglynO8imgWvtvtw61ZvQrtVnIV8zeZ001Wncr6+CUqJ9Gm2H9w6SmzXeO82kToKMbYf2tTZexXi995KO7b3TVxMu125YmbEB+3WmqBmbmTMogDalB/GQVKSSahI5T7Ywo2FSxG5qRrRLe65SK0L9oElYR1L/J1HY12B2lAOU/XoCUy5ivq0eaYh+H3unPrmYfrzkU+70aRxtmY2SlmjyYkawNodsVs9g84Ccm767QBIoPwXFu3DM0GNAVuO/uWuBrQggOtaC7wTuSbjlNIWpFfuA0fzHIrgaxHm3lEy74S+BQ+0u+I+QKmv6hhI5pV8xqk4OxAW5uNxhHWbqTRbGfmjfgo0zfRetHKDPehNIiSlWM20cl9gVFEqA+htZBWohU7f0C5wNagZNwzURLtZfg5lfMNeRRw2cH0lkmZDwjQrIkSfh33OJyL1p3ahhbtm40G/whK1VmBJu6Po+WTwvmGASKC96FNNq7CL4y4LxAgQl1k5egh+Zv3IvltRsS1GMn4T0le3qcHrVN2EfruHyL3UmGG5c2hQaWV8q3YKuCicvsL7v37swwzxVXAU2gL9+jSO850/Coyfy+n+oYD+xNnoClSSUsAzWe0oHXdvkN1M+1SFFD6OHMjawHaHfoxpEXH5RJm0OKKTwD/zb5f+juDyvhL4HNTuL4B1ePTiOAnQxcitZXMvk6zaBmrx9Bqr0D8FJNw8uj+gHv/QtviK0Aj7Ajxe9M5/+Dj9u+5yh17PnAWGkVnuqHC/kQjSnFxS2wn4YtotdNrJ7luqqhByyflkUYQp4VMII1uBJFBa8w1zycm0CIBbmbJZCjh5XiyHMk8WvTzAbRwwWzrNEArzEIo4JbOiZs7dCOtyq3sGYcMWi/cOTXno4bl1kIbYGGmeKxEnayP6p3GTXSfqwBIHrkyAqQ9JaEF3+7Nc/TuqaLJ3jnK1HINRxHxg58LHIcMXhv/7kwLF0EzqqshQm6JlLDmDt2IsAZJ7uhNKKcsurvLfEILMlX2sDAJ6whERgPsW99nmLCqaS9vsWuLlAee9gWakQyOMDXCcktXQ3UTrx5pq+uZO6282X6DhHyBC9FPNF9xBOogjxG/ckQGpWm0I7L6Cb4h8sgR24k2ediJGmsFXhW/iUqCq0ME43wGtSgiGxfwqLPnLcWvU34L6txtePP0bPv7e0TCJStv2PmeQaZXG5qsXrRjN+AFNmvl6kYBlQftusUokbgJmVE3U10bqkWm00movjIoELPL7skg34nDUcjsqkWzJ1znnLBjR9vzhu374xzPWbtmudXLKDLzqwWiulBbbCfZ0VyPdtkZRcuRRxcBCOyaZvsOV+YfEU8wdUhmulHdbkBtlSN+5/SlVsYr8GTuZpm46XPXUi6/LmvAyVdcfV2I5OkhJh8kskh2mlFbuDq4AV9vGTSwNyFf719w0CQPTzE1uG208sjp+HjkfIA2MD0XCdOXUGj7z6gB3wu8GE2L+hcUDj4NCWk9IpEXU77LcTOalH4CEtIHgOeAdwP/Q3kouRFFMF+BhLoX7YzUiMjxRLtvNYpkvsiesQz5ZfqB39qzMoj4PoXSUDYjTaEOmQVuNY53I3LaCvwzIsZD0OqwfcjPsxIt2bMVPyUsXGeHWZ0dg1a5fcTq7x+AZ9Hu1TkU5HgTmvf6ckS2Tfidpd1Ur1OBPyHyuQztv9mL2sEhhyK5p1o93AH8AUX3SiSvtHsGcDgi5rspJ4sAheg/iQhmHdorMEpYr0P1eiRyjLt0i1MRIYTrqBWl07zR6uYpFEBYgbSdh5E8ONSgnMg34PduqLVrG5Hsvt++Pyxni5BWeIgdj6YoLLPnXgH8JqFuHDIoVel8K/9GNLgsQqkWT1qZa+ybX2Vl/W34ASlmD6cxlFDDR6Nrb0UNuxPtNhTex7HRzl+KOvVlyHl5DeqgZ9s1i0LPy6HNa/P2vB32vF2IOM5ChFCya9+LBPsTSAOqQR3wLPxWUPcgjelS1MEusXe5YIFDJxpRNwLfxGtUA/idjm5Enf5qJOSBvesB5ONwmuITVrYVVG5f1Y4c40PAV/ApIL3AO/H7E26zsgaI/NrRYHCjXe8SHTtRZ70ckUADckDfj9caMsBHUcf9KtJqJ4CT8drxBuLzp5bZ3zGkHYWxGHVIt5XXJiq18EbUpgXUpm47sV6kGZ2Mr6MmlN/USnmeU5PdC5UR0jzwWvueHXb+BHvfFlSHDZTLGXa+QHwiqXO0/zRU3mpYhpaouhMtuOlkpxdFI1ciWaxF7eV2C/oLUsKaG7QjgdtOfJLcRuD7iFCiTt4PoJF+DwrjBsAvkLkSoNF6AC+IDUiwV+NzucLzP49EI5U75nJ/9uIjPkcjTWcLfvuoUdQpm5BZGmfWdqCOPIwEK+yvaMDvn3e0fecm1Hkb7PgdVJq1GSo7VzsasTP2vmi+2lPItFqDOrErx+H27yghBKhj/Rh1vo9bXTyDr5OsHf8Ympu6zr6hBRFYMxpA4pz0rWjQGrBnRrEbycYO4rPLW1BbtqO9B8OdvxYR7c9C//8Cav/PUy5vOxEh7aKSVBsoX0X4BNSOD6F6/jl+wAyjaL8ADWhuu70skt061K6TmYLL0RZ/u6mUnRYkAy6ZugnV54+ImNcpYc0etcg0yiCBvGOa9w8hIQ7QCDiMhMJ1pP8KXZtBZs+JSLO4F7/PXh0S4nHU0A4uYdD5gXqsnFcgwirYdVl7Tg4fGQqjDvgsEvwfIMGrtf83I63ndivXMnvGCBI8kEM2qkU1W3kLoWNZ4BTUeW8mPrn2JfZdB+MDR81Wlr1UkmKA36OvFpm9Q5T7pJYg8yigfPPVYURgj6F6jfNhdVi5B1CbJJmNccghs3cFkp1N+B2vnc/rCfw6bMvRYLMBtV8YTVb+HioJqw2Rwqg9cwiRlSOkrxO/V8NuRCQdiDhvsOOdyFS8kup7QYAGsgtR3d+J2qfOvq8FmX/fwRN1h/19kkh6UEpYs0cD3um7cQb3r0OjUw0SqmGSd/fNIVKrQY1/Lr6j5JDg3ET56DWIhP10NL1hj/0up3Ikfy0S+LAPw6HVyldCvqVP41fWqEPm3oNIwLaEnv16vBkS1U7eYGUOd/BWpCUGyA8Tp9HEJYR2oQ7QQ2WkagIR9F6kRXYhTWObnQ/s2BK7vy907xgisJtj3umw0v7uYvqR1XpU7xlEOJ/Er2ySt7LchSeF01Cbb6byO7vt3C+pJKw34wMULciMa2TyaKozqaM4FZH4VGZrdNg7A6QFN6J2HUZteSeSUTcYvAW/yW3ZAJES1uxRhwR9iKltIx5Fwf6uQaPqJpJDw614cgz7dcbxSX5RDaCAOuufkK+sDhFPMzKTnEnhiLeX+ChXFxK0Xnv3cOid4b+uPONIS1qMiCIaueyy7+mnnDiXIAHfSzxxBkjLGEMjcDF0Xz0yp+O0oAEk7yvtW2/Hj951yHGcBW6lMum3GuoR8Y4hU3U694Kvo1E0iDjt0JFEuE2XIFIqEB9ZPQ7VWz+VJHSU3eP8fecgU/diJk8idc/Ko4FtDarDK5nalCbnMtmBZMd9U5FK2alB39hPTGQ0zcOaPdpRJe9h5jkozj9Qi9T/pGTGGvx0jkfxm2+MIMGJCnA98idlgH9Fkcq1aDRrQYLn0ISEcEfoOXlkqrh/Z+1dPfbeIXtv3Ox9ECE1UpnT5TSaBrym0GnX5uw3RrwfrdPuG7RyuND/ofhMcoclqF4dGpF2OIIGBkfSNfj0kelOSm+25zpNcbq5X7X41ROcTzHsVwy3aR3erIvKmkuHcAm/TchZj5WvERFALwo0XGXPujj0jGXEz75wplk7Ir6zkT8wrn3ikEOyM4SIaC8a8OJkpw2vWQ4SacOUsGaPt9nfzcw8azqLQrg1JO+IDeWCmtQx2lCnzqOw91eQz8vdswOFiguUd4ZOe/9G/Hd0oKgOSMCqaQ8ZJPCNoWMtqANsjVzrIqMBfnu2c+x+J5NJneEkVF8P4TXaZiur6xAO5yB/j0MH0s5+gifJ8/DzPsdI1hgakDkZxVL0jcPMbE22ESb3AXXiNwouoQEg6ifrRm2+286vxufULUN19iu8/IzZLxd6xvn2rrgylvDpOb3Ea79JGGVyzfNoJH+ujp+x8p2OAgRASlhzAWeehDWT6aIZCb5T55MwgLQKJzxhBKjBz0Mdsx75ApzDOYx2JEC3hY5lUafbg0+HWIV8HeCjcXFE6Rz/5+FH6DzyX5WozOhuxa8GMWDlqUXa0bD9amPe04X8WzvQygDObMpY+bfjO4bTKpyzOoc6Wwn52jL23q2IvHvsGeEOTOjeM6gkrBwy52oQURRi7p0M/SRrZgGqR5e3tAfVTYHyRN4a9G0BIqUiSmR+1s4fiepqN+WyUMKb44vxMxyimLBr21CdXsf0TN9+kq0P1w5r7Tuy9uwdqH5fT6hPpIQ1fQSocV20pgFVcA3ezzNduMzfHqr7BEaQj2UPGjWdD7IG+WYuRwK5DgloAfkZnBaTQSPocSjNohB69igijxF73hnAK/FrmW23d+fR9wf2a0S5VJeg0HuPXV+H1PkC8b69EnLaZhERbERCvQVpQDmrkwC/M/g5Vs7PUK5hFO17t+Lb5yJEtuEBIItfBrvVnv8g6vzfR513Cb5enZP688iU/KYdb0SEuxo5kQN7f3eobqaKPajeRu1+d28emexfRonI96P2eQR18GV2XT3KP2uyb+vHm/cP4oM5Q5Sbu87P+Diq65WoPeIinNvwmfPrmVrOVRgPIcd6Hg1sDk3Ah1Du39V4F4NzO7i22OBuSDPdp4+XAP+EnLRu5HoOCcUy1LDTadAAjSJvQ+HzycyK36Is9A+isP6r7b3LkTB/Fwnic0iA6+yaDjTqHoFG4RspHyWdj+IQlHF9KNJiwnk+PYjwjrDnvg7VwSFIW7sHnzW+CDl1N1EeAQKtPNuICLHW7rkLZZSPIz/eK1Fka5F92zHIr3ENytIOZ6eP48m4FhHg4yiX7f/smgmrjzfa/xutvnbaNYOIPNbYu1+FSMplYF9v12TQApMfQp38Zag9Xor8fQczyfpNMXgG+Cs0O+BgRHorUfTw55SnUzyJ6t1p0Z0ooPJDe8ar7b4+NMA0ozSR3fac/w3V2UEoYLDI7lmH18rC+AMalHaj+h+OuaYa/owCEoejGQn1SOZXI0K9CW9i/h4RlWv/jShaDGjqQYrpIcBPco2ihEaJwjSf2YCEtGeK92aRwOaRIDvf1l7KTYsAaRINqKMFSNj6qFTpneO/yZ7ZR7wfqdGuy+BJYJBKP0wN6kwDxIfOm+05RXtXnBN5MX5ttEGkPSSZIu594OcPRq/Noc5Qa+/bTTmxZPAR1KLdP2zld9c5rTKfUI5RK+tMnO9L7Dsm7Bucczr6rHAbDCGiHUPt3GFl6Ld7c0hLdN8bhrMKAntXH8lEuxJvOs8UTVbuAN9XXNAoDJdCU7Ay/8Xq+H+w0mK5dossTgAAAABJRU5ErkJggg==" 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 & 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 & Diastolic flow components in relation to Spectral Analysis <question> Peripheral Art: <span style="text-decoration:underline;">Correlative &/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 & highlights ART lumen -Images of highlighted vessels of interest are recorded Peripheral Art: <span style="text-decoration:underline;">Correlative &/or Prior Imaging</span> DSA -Same technique used in Cerebrovascular Peripheral Art: <span style="text-decoration:underline;">Correlative &/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 &/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 &/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 &/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 & 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 & 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: <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 & 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 & 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 & passed beyond the clot. A balloon in inflated & 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 & surgically opened in the region of Atherosclerotic disease -The Intima, Media & 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 & 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 & 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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Bypass Graft (Reversed Saphenous)</strong> -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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Bypass Graft (Non-reversed Translocated Saphenous)</strong> -GSV is removed & 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 & 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 & 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 & 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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endovascular (Endograft)</strong> -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: <span style="text-decoration:underline;">Treatment Surgical Therapy</span>-<strong>Endovascular (Atherectomy)</strong> -A catheter w/ a rotational device cuts & 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> & <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 & 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 & causing ART thrombosis w/c can lead to Emboli, Stenosis or Occlusion