# CCI RVS

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 Author: marie78 ID: 282089 Filename: CCI RVS Updated: 2014-09-05 22:02:55 Tags: RVS CCI Folders: Description: CCI RVS Show Answers:

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1. TOPOGRAPHIC ANATOMY
Body in anatomic standing position
2. Sagittal Plane
• aka Long
• Vertical plane that divides the body into 2 halves w/c is the rt/lt portions
3. Transverse plane
• aka Axial plane
• Horizontal plane w/c divides the body into Superior/Inferior portions.
4. Coronal plane
• aka Frontal plane
• Vertical plane w/c divides the body into front and back portions
5. Proximal
• Closer to the point of attachment
• Origin of flow in cardio vascular relationship
6. Distal
• Farther fr. the point of of attachment
• Farther from origin of flow in cardio vascular relationship
7. Hemodynamic
• Hemo=blood
• Dynamic=power
• Po difference betw 2 pts in a vessel
• LIQUID ALWAYS FLOW FR HIGH TO LOW Po
9. Viscosity
• Thickness or stickiness of a fluid
• Unit: Poise
• Bl viscosity is 4x that of water
10. Friction
• Resistance to motion caused by 2 moving obj that are touching each other
• Vessel walls and flow of blood causes friction, therefore, providing Resistance to flow
11. Inertia
Velocity of a fluid changes

If at rest it tends to stay at rest.  If moving, it tends to stay moving; therefore, Po must rise to a level that will overcome inertia
12. Poiseuille's equation
• Mathematical equation used to predict the vol flow rate in long straight vessels
• Q=ΔP/R

• Resistance =r(Biggest factor)
13. Plug flow
• Flow vel is uniform across the lumen
• Found at entrance of large vessels
• "Normal" flow
14. Laminar flow
• Fastest in the center
• Vel drops as it moves closer to the walls known as Parabolic flow
• "normal" flow
15. Pulsatile flow
• Contraction of the heart produces a change in Po.
• Art expand in systole and Contract in diastole
• Due to change in diameter, Resistance to flow also changes
16. Turbulent flow
• Many diff vel
• Chaotic
• Caused by abrupt changes in vessel's lumen
• Usually due to Stenosis caused by build-up of plaque
17. Phasicity flow
Venous flow patterns in lower extremities
18. Inspiration
• Diaph: Down ↓
• Venous ret from legs: Decr ↓
• Venous ret to heart: Incr ↑
19. Expiration
• Diaph: Up ↑
• Venous ret from legs: Incr ↑
• Venous ret to heart: Decr ↓
20. Hydrostatic Pressure
• Gravitational forces
• Venous Po changes when pt is supine or standing
• Supine: 15 mm/Hg
• Standing: 102 mm/Hg

Art Po changes are much less dramatic w/supine or standing positions
21. Doppler U/S
• Difference between reflected (fr) & transmitted/incident (fi)
• Meas. by Velocity
• No fD occurs at a 90o angle
• If fr is > fi = +fD
• If fr < fi = -fD
22. +fD (positive doppler shift)
• Reflectors (RBC's) moving toward the sound source  0 <60
• Above Baseline
23. -fD (negative doppler shift)
• Reflectors (RBC's) moving away from the sound source 0 <60(away)
• Below baseline
• Peak systolic vel is increased
• Represents disturbed or Turbulent flow pattern
• May be assoc w/ critical Stenosis
25. Pulsatility Index (PI)
Calculated by dividing the Max (A) - Min (B) velocity by the mean (avg of the signals) velocity

26. Resistive Index (RI)
Calculated by subtracting the Min (B)- Max (A) and dividing by the Max (A) velocity

27. 3 layers of the Artery
• Tunica Intima
• Tunica Media
• Tunica Externa
28. Tunica Intima
• Thin layer
• Consists of Endothelium over a base membrane and connective tissue
29. Tunica Media
• Intermediate layer of the ART wall
• Thicker than Intima
• Composed of smooth muscle and connective tissue (elastic type)
• Arranged in a circular pattern for strength
30. Tunica Externa
• Outermost layer
• Thinner than media
• Contains fibrous connective tissue & a few smooth muscle fibers
• Arranged in longitudinal pattern
31. Aneurysm
Bulging of all 3 layers of the Arterial wall
32. 2 things blood needs to travel through
• 1. Route - ART system is a conduit (tube)
• 2. Pressure gradient = Vol of bl flow (Q)

Flow occurs from HIGH to LOW
33. HIGH Resistance flow
Has a High Systolic peak & Low Diastolic flow
34. LOW Resistance flow
Has a more Rounded Systolic peak and a relative high level flow in Diastole
35. Carotid Anatomy
• Innominate Art (IA) divides into RT Subclavian Art and RT CCA
• LT Subclavian Art & LT CCA originate dir fr the AO arch
• Variation occurs to LT CCA arises fr IA
36. Internal Carotid Art (ICA)
Commences at the carotid art bif at the sup border of the thyroid cartilage
37. 4 Segments of the ICA
• 1.Cervical portion of the neck
• 2.Petrous portion
• 3.Cavernous portion
• 4.Cerebral portion in the brain
• Ophthalmic Art is the 1st branch off the ICA in the skull

• No branches arising fr the ICA in the neck
• ICA is usually (not always) post-lat to the ECA
• It is usually larger than the ECA
38. 8 Branches of ECA
• 1. Superior Thyroid Art
• 2. Ascending Pharyngeal Art
• 3. Lingual Art
• 4. Occipital Art
• 5. Facial Art
• 6. Posterior Auricular Art
• 7. Maxillary Art
• 8. Superficial Temporal Art
39. Key methods of differentiating ICA/ECA
• ECA has extra-cranial branches
• ICA has lower resistance flow than ECA
• ICA is larger in diameter (but can appear smaller if there is a disease)

The wishbone or turning fork bif is only found in approx 15-20% of pts.
40. Vertebral Art
• Important branches of the Subc Art
• Travels betw the TRV spinal processes toward the brain
• LT Vert Art is usually larger than the RT & enters the skull thru the Foramen magnum
• Supplies the POST portion of the brain
• Vertebrals join to make the Vertebrobasilar circulation (Circle of Willis)
41. Pitfalls in Cartotid Art duplex Scanning
• Incorrect differentiation of the ICA & ECA in diseased bif
• ECA is usually smaller than ICA but NOT always
• Improper Doppler waveform patterns & characteristics sounds to distinguish the ECA from ICA
42. Plaque Evaluation
• Calculate the % of diameter reduction:
• Measure true vessel diameter (TD) and residual lumen (RL) in TRV plane= Plaque diameter. This is only a rough estimate of the degree of stenosis
43. Percentage Diameter Stenosis
%D=PD/TD x 100

• PD: Plaque diameter (true vessel diamter-residual lumen)
• TD: True diameter of the ART

• Tool to indicate when carotid endarterectomy is warranted
• Intersocietal Commission for the Accreditation of Vascular Labs (ICAVL) requires from these popular ones:  Univ of Washington duplex criteria and North American Symptomatic Carotid Endarterectomy Trial (NASCET).
45. Carotid Stenosis criteria
46. Degree of stenosis
• 0Stenosis         ICA PSV             Plaque Est
• Normal            <125cm/s               None
• <50%             <125cm/s            <50% DR
• 50-69%         125-230 cm/s         ≥50% DR
• ≥70% but        ≥230 cm/s           ≥50% DR
• >near occlusion

• Near occlusion  high, low or         Visible
•                       undetectable

• Total occlusion   undetectable       Visible, no
•                                                lumen seen
47. Normal Vert Spectral Waveform
• Low resistance pattern
• Well defined systolic flow
• Sustained flow in diastole
• Peak Systolic Vel range fr 20-60 cm/s
• One may be larger than other
48. Subclavian Steel Syndrome
• Most common condition affecting the Vert Art
• Bl that is destined for the brain thru the Vert Art is shunted away due to high grade stenosis or complete occlusion of the IA or the Subc Art proximal to the take off of the Vert Art
• Flow is reversed in the Vert Art that is supplying the arm

*There will be a substantial diff in Brachial BP
49. LT Subc Steal
• Pathway of bl flow in the LT Vert Art when there is occlusion in the LT Subc Art proximal to the take off of the Vert Art
50. RT Subc Steal
• Pathway of bl flow in the RT Vert Art when there is occlusion in the RT Subc Art proximal to the take off of the Vert Art
51. RT Subc Steal due to occlusion of IA
• RT Subc Steal due to occulsion of the IA
• Flow in the RT Vert Art is reversed
• BP in the RT arm is decr ↓

52. LT Partial Subc Steal
• Flow in the RT Vert Art is antegrade
• Flow in the LT Vert Art is demonstrates antegrade and retrograde flow components
53. Facts about Subc Steal Syndrome
• Most pt are asymptomatic
• Claudication is rare
• Brachial BP diff of 15-20 mm/hg
• Pulses ↓ on affected side

Flow resistance in supplying Vert may ↑

Surg. treament: Stent, by-pass graft, endarterectomy
54. Subc Art Anatomy
• On the Rt side of the body, the Subc arises fr the short IA (brachiocephalic art)
• On the Lt side of the body, the Subc arises dir fr the AO arch
• RT/LT Subc supply bl to the head & arms
• It is located below the clavicle
55. Branches of Subc Art (both sides)
• Internal Thoracic Art
• Vert Art
• Thyrocervical trunk
• Costocervical trunk

• At the Lat border of the 1st rib, the Subc Art becomes the Axillary Art
56. Spectral Waveform of the Subc Art
• High Resistance
• The Incr resistance feeds the high resitance art of the extremities
57. Cerebrovascular Disease Symptoms:
• 1.Cerebrovascular Accident (CVA)-complete brain stroke cause:
• Embolism, Thrombosis, Hemorrhage
• 2.Transient Ischemic attack (TIA)-Symptoms resolve w/in 24 hrs
• 3.Reversible Ischemic Neurologic Deficit (RIND)-Symptoms resolve, but not w/in 24 hrs
• 4.Death is also a possible consequence of stroke
58. Common Hemispheric Symptoms & Assoc. Hemisphere
• Aphasia
• Dysphasia
• Dysarthria
• Lateralized paresthesia
• Hemiparesis
• Hemiplegia
• Amaurosis fugax (AF)
• Ataxia
59. Aphasia
Inability to speak or express oneself (dominant Hemisphere, usually LT)
60. Dysphasia
Impairment of speech, lack of coordination & failure to arrange words in proper order (dominant hemisphere)
61. Dysarthria
Imperfect articulation of speech due to disturbance of muscle control, slurring, etc (dysfunction of any # of brain centers)
62. Lateral Paresthesia
Tingling & numbness (contra lateral hemisphere)
63. Hemiparesis
Lateralized weakness (contralateral hemisphere)
64. Hemiplegia
Lateralized paralysis (contralateral hemisphere)
65. Amaurosis Fugax (FA)
• aka Transient Monocular blindness (TMB)
• Related to ipsilateral art
66. Ataxia
Gross uncoordinated of muscle movements, clumsiness of limb (contralateral hemisphere)
67. What is STROKE?
• 3rd leading killer in the US
• Occurs when a bl vessel in the brain or feeding the brain bursts (hemorrhagic stroke) or is blocked (ischemic stroke) causing a sudden disruption in the vascular blood supply to the brain
• One of the warning signs of stroke is a TIA
68. TIA Transient Ischemic Attack
• Neurologic deficit that reverses w/in 24 hrs, but usually resolves w/in minutes
• Has no lasting damage
• Affects Anterior circulation
• Bl clot temporarily clogs an Art w/c is feeding the brain and it doesn't get bl
69. Risks of TIA
• If you've previously suffered it b4
• Risk for CVA is ↑ Incr by 10% w/in the ff 3 mos
• 17x Incr during the next 5 years
70. TIA Symptoms
• Blindness in 1 eye (Amaurosis fugax)
• Dysphasia or Aphasia (Speech difficulties)
• Contralateral hemiparesis/monoparesis (paralysis)
• Behavioral disturbances
71. RIND symptoms
• Neurologic deficit that last longer than 24 hrs but less than 72
• Occurs when bl flow to brain is temp restricted sudden onset of symptoms
72. Amaurosis Fugax Symptoms
• Transient blindness in one eye
• Last from seconds to minutes
• Similar to shade being pulled up or down
• Caused by temp blockage of small bl vessels in eye
• May be occasional or repeated many times/day
• Disease is on same side as affected eye
73. Bruit
• Abnormal low rumbling sound
• Heard thru stethoscope over the CCA
• Caused by turbulent bl flow as it rushes by an obstruction
74. Bruit may indicate:
• Stenotic area
• Tortuous vessel

*Majority of pts w/ bruits have a stenosis of 50% or more
75. Hemispheric Symptoms
• Aphasia-LT Hemi
• Dysphasia-LT Hemi
• Dysarthria-LT/RT Hemi
• Lateralized Paresthesia-LT/RT Hemi
• Hemiparesis-Contralat Hemi of Brain
• Lateralized Weakness- Contralat Hemi of Brain
76. Vertebro-Basilar Insufficiency (VBI)
• Post circulation affected
• Flow in Vert or Basilar Art disturbed
• Symptoms usually bilat
77. VBI Symptoms
• Vertigo (most common)
• Ataxia -muscle coordination
• Weakness in limbs
• Drop attacks
• Paresthesia
• Visual Disturbances
• Numbness around lips/mouth
78. Vertigo
Sensation of things moving around in space
79. Drop attack
falling to the ground w/o loss of consciousness
80. Paresthesia
Numbness or tingling
81. Carotid Artery Aneurysm
• Dilation of all 3 layers of the Art
• RARE
• Caused by trauma, infection, congenital carotid art, thrombus may form around vessel walls

Portions of thrombus may break off and travel to the brain
82. Atypical Disease Condition
Pulsatile neck mass in the CCA
83. Atypical Disease Conditions include:
• Fibromuscular Dysplasia (FMD)
• Carotid Body Tumor
• Carotid Dissection
84. FMD
• Dysplasia of the media w/ overgrowth of collagen
• Part of collagen vascular sys disorder grp
• Mainly in WOMEN
• Bead like appearance on angiography
• ↓ Bl supply to the brain
85. Carotid Body Tumor
• aka Paraganglioma
• Located next to carotid sinus betw ECA/ICA
• Small mass of vascular tissue
• Functions as chemoreceptor
• ↑ Vascularity
• Bl supply via ECA
• May require surgical treatment
86. Carotid Dissection
• Separation of Intima fr media
• Separate flow channel w/in dissected wall
• Proximal dissection
• Distal ICA dissection

87. Causes of Carotid Dissection
• FMD
• Trauma to neck
• Congenital weakness of the media
• Chiropractic treatment
• Idiopathic (don't know)
88. Surgical Intervention of Atypical Disease Condition
• Endarterectomy
• Bypass Graft
89. Endarterectomy
• Surgical removal of the intraluminal atherosclerotic material
• Surgery not performed w/ complete occulsion of cervical CCA or ICA
• Decision based on extent of disease, severity of disease, pt symptoms & medical condition
90. ByPass Graft
• Provides alt pathway around stenosis
• Rarely performed for ICA disease
• May be performed for stenosis in
• Proximal CCA
• Subc Art
• IA
91. Correction of Coiling, Kinking, tortuosity
• Shortening procedures
• Sometimes performed w/ endarterectomy
92. Tortuous Vessel
• May cause bruit to be heard over the area
• Due to ↑ Vel & turbulent flow assoc w/ tortuous vessel

93. Circle of Willis Description
• Most important pathway for collateral circulation to brain
• Vascular channel of intracranial comm.
• Located at the base of the brain
• Connects Ant/Post circulation
94. Circle of Willis Anatomy
• Hexagon like arrangement
• Ant Cerebral art
• Middle Cerebral art
• Post cerebral art
• JOINED BY:
• Ant/Post Comm Art
• SUPPLIED BY:
• ICA & Basilar Art
95. Circle of Willis Collateral Pathways
• 1. Hemisphere pathway
• 2. Post-to-Ant pathway
• Both ensure bl will not be compromised in the event of stenosis or occlusion
96. Contralateral Hemisphere of Circle of Willis
• ⇒AO
• ⇒To LT CCA
• ⇒To LT ICA
• ⇒To LT ANT Cerebral Art
• ⇒To Ant Comm Art
• ⇒RT Ant Cerebral Art
• ⇒To RT Mid Cerebral Art
97. Post-to-Ant Pathways of Circle of Willis
• ⇒AO
• ⇒To Subc Art
• ⇒To Vert Art
• ⇒To Basilar Art
• ⇒To RT PCA (Post Cerebral Art)
• ⇒RT Post Comm Art
• ⇒To Dist ICA
• ⇒To RT Mid Cerebral Art
98. Transcranial Doppler Technique (TCD)
• Duplex imaging of intracranial circulation
• Pt position: Supine
• Pt must abstain fr movement during exam
• TX: 1.5 Mhz - 2.5 Mhz small footprint sector
99. Acoustic Windows for TCD
• Transtemporal approach
• Transorbital
• Transoccipital
• Submandibular
100. Transtemporal approach for TCD
• Ant & slightly Sup to ear
• Can visualize the terminal portion of ICA, ant cerebral, mid cerebral & post cerebral art
101. Transtemporal Windows for TCD
• Art         Depth(SV)      Flow dir        MeanVel
•                 (mm)                             (cm/s)
• MCA         30-60           towards        55 +/-

• MCA/        55-65           Bi-dir
• ACA

ACA          60-80           away           50 +/-

PCA          60-70          towards        39 +/-
102. Transorbital approach for TCD
• Probe placed on closed eyelid @ inner canthus of eye
• PWR must be reduced
• Ophthalmic art & carotid siphon can be eval
103. Transoccipital approach to TCD
• Probe placed bet post margin of foramen magnum (FM) and 1st cervical vertebra
• Basilar Art & Intracranial portions of Vert Art can be eval
• Pt s/b in prone or sitting position
104. Transoccipital Window for TCD
• Art         Depth(SV)      Flow dir   MeanVel                    (mm)                          (cm/s)
• OA          40-60          towards      21+/-5

• Carotid
• Siphon     55-80

• Supraclinoid
• genu        55-80        away/         41+/-11
•                               bi-dir

Parastellar 55-80       towards       47+/-14
105. Submandibular Approach for TCD
• Probe placed under the mandible
• Petrous portion of ICA can be eval
106. Submandibular Window for TCD
• Art         Depth(SV)      Flow dir        MeanVel                (mm)                             (cm/s)
• Vert        60-90            away          38+/-
• Basilar    80-120           away          41+/-
107. Peripheral Arterial Duplex Imaging Lower Ext
• 1. Rt SFA
• 2. Rt Tibioperoneal Trunk
• 3. Rt. Peroneal Art
• 4. Rt. CFA
• 5. Abd AO
• 6. Rt. CIA
• 7. Rt. Post Tibial Art
• 8. Rt. Ant Tibial Art
• 9. Rt. EIA
• 10. Rt. Internal IA
• 11. Rt. POP Art
• 12. Rt. DFA (Deep Femoral Art) or Profunda Femoris Art
CFA →POPA
• CFA bif into SFA & DFA
• CFA arises inf to Inguinal Lig
• Then divides into DFA and SFA
• Profunda Art (DFA) lies Post & Lat to SFA
• Then supplies bl to thigh muscle & hip joint
• DFA is deep to the SFA
• SFA runs the length of the thigh
• Terminates after it passes through an opening in the tendon of the adductor hiatus (aka hunter's canal)
• Proximal SFA is superficial but dives deep as it travels into distal portion of the thigh
• POP Art begins the opening of the adductor magnus muscle & travels behind the knee →
• Pop fossa
• Major branches of POPA incl sural & genicular art. Gastrocnemius may also be seen as it takes of fr the POPA
ATA → PTA
• ATA branches fr the POPA and travel laterally & anteriorly to the ankle
• Dorsalis pedis art is a continuation of the ATA on top of the foot
• Tibioperoneal trunk is the next branch off the POPA.  Pero Art and PTA arises from it
• Peroneal Art supplies Lateral side of calf & calcaneal region
• PTA extends obliquely down POST and Med side of leg & passes POST to Med malleolus
• PTA runs obliquely down the Med POST part of the calf.  It is POST to the tibia & terminates POST to the Med malleolus
• It then terminates as the Med, Lateral and Plantar Art of the foot