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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Peripheral Arterial Anatomy-LE (CFA)
- -Originates @ Inguinal Lig
- -Continuation of the EIA
- -Courses LAT to CFV & divides→DFA & SFA
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Peripheral Art-Uncontrollable Risk Factors
- -Incr age
- -Family Hx
- -Male gender
- -Thrombophilia: hereditary risk toward development of thrombus (Bl clot)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 Pain2. 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 ↑
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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