Arterial Pressures Lower and Upper Arterial System Testing Non-Imaging
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What should the temperature of the room be for the patient?
What are the two methods for non-imaging arterial testing?
3 cuff method using contour cuff and 4 cuff method
Where is the disease present to abnormal pressures and indices?
proximal to the cuff
What is the advantage of 4 cuff method?
What is the disadvantage of the 3 cuff method?
Advantage- can differentiate aortoiliac disease from SFA disease.
Disadvantage- false high pressure with narrow cuff.
What are the cuff sizes in...
- Brachial- 10-12 cm
- Ankle- 10-12 cm
- BK- 10-12 cm
- AK- 12 cm
- HT- 12 cm
What is the disadvantage of 3 cuff method?
Cannot distinguish inflow from outflow disease with 3 cuff method.
What must you do when taking pressures in the leg? Hint- Where do you start?
Must start at ankle and work upward.
PTA and DPA
If you begin at thigh may create hyperemia reaction.
What are the normal indices in the leg?
HT/Brachial index > 1.2
Ankle/Brachial index >= 1.0
What are the abnormal indices in the leg and the meaning?
HT/Brachial index is 0.8-1.2 = Aortoiliac stenosis-Inflow disease
HT/Brachial index is < 0.8 = Iliac occlusion
What does abnormal indices between what cuffs represent disease where?
HT to AK = SFA disease
AK to BK = POPA disease
BK to Ankle = Tibial and Peroneal disease
What is the ABI's indices?
- > 1.25 = Medial Calification
- 0.97-1.25 = Normal
- 0.75-0.96 = Mild (single level)
- 0.50-0.74 = Moderate (multiple level)
- < 0.50 = Severe
What is the symptomatic indices?
- > 1.00 = Normal
- 0.90-1.00 = Asymptomatic
- 0.50-0.90 = Claudication
- < 0.50 = Rest Pain/Limb Threatening
What is the TBI's indices?
- Normal = 0.80 - 0.90
- Intermittent claudication = 0.35+ or -.15
- Rest pain = 0.11+ or -0.1
What are the steps for the treadmill exercise? (5)
What are you looking for after exercising patient?
- 1.) Do resting study- Need baseline
- 2.) Simulate symptoms
- 3.) 2 mph at a 12% grade for 5 minutes
- 4.) Note: Duration, distance and symptoms
- 5.) Return patient to supine position and get ankle and brachial pressures within 30 second- 1 minute and get every minute after.
Looking for the patient's pressures to drop after exercise!
What are 3 limitations when exercising patient?
- 1.) Patient effort
- 2.) Patient motivation
- 3.) Pain tolerance
When should you not exercise an patient? (7)
- 1.) Medial calcification
- 2.) Hx of unstable angina
- 3.) Recent cardiac Hx
- 4.) Unsteady gait, balance
- 5.) Index of 0.70 or less at bryan or 0.50 or less
- 6.) Amputee
- 7.) Wheelchair, cane, walker
In the case that you have a swollen leg should you do an arterial segmental testing?
No, you should do venous first to R/O DVT.
DVT would cause fluid build up because occlusion.
What 3 things should you note when exercising patient?
- 1.) duration
- 2.) distance
- 3.) symptoms
Why should you not treadmill exercise a patient with medial calcification? (2)
- 1.) Pressures will still be 250+. =Noncompressible.
- 2.) Nothing to compare too because can't take BP to start with.
What is the main purpose to watch for after exercising patient? (2)
What does it signify?
1.) determine amount of immediate decrease in ankle systolic pressure.
2.) identifying the time of recovery for resting pressure
How much BP drop = how much disease they have
What are the normal results of exercising patient's?
the patient's BP should slightly increase in pressure
there should be no change in ankle pressure compared to resting pressure
What are the abnormal results of exercising patient's?
Minimal disease -
Single-level disease -
Multi-segmental disease -
Minimal disease = BP returns to baseline within 2 minutes.
Single-level disease - BP returns to baseline within 2-6 minutes.
Multi-segmental disease - BP returns to baseline > 10 minutes- Bryan stops at 5 minutes.
What is another way to non-imaging arterial testing if you can't exercise the patient?
Reactive Hyperemia Testing
What are the steps for RHT?
- 1.) Patient is supine.
- 2.) Need to do rest study B4 RHT
- 3.) Place cuffs on HT and ankle
- 4.) Inflate HT cuff suprasystolic for 3-5 minutes
- 5.) Measure ankle pressure at 30 seconds post-release of HT cuff and at 1 minute and every minute there after.
What are the normal results for RHT?
Initial drop in pressure which returns to baseline within 1 minute.
What are the abnormal results for RHT?
-Prolonged pressure drop.
< 50% in ankle pressure = single-level disease
> 50% in ankle pressure = multi-level disease
What are the disadvantages of RHT? (4)
- 1.) PAINFUL
- 2.) not as accurate as treadmill testing
- 3.) Ischemic effects are not as prolonged as with treadmill
- 4.) Cannot be used on grafted limbs/stented.
Which type of plethysmography is filled with metal/mecury?
What does true plethysmography do?
measures volume changes.
What does the PPG sensor do?
What does PPG stand for?
Is it true plethysmography?
detects cutaneous blood flow.
No not true plethysmography
What is the type of true plethysmography?
Pnemoplethysmography or Air-filled
What causes with The Dicrotic Notch in Pulse Plethysmography?
Soft tissues of the extremities EXPAND and CONTRACT as blood moves through them with each cardiac cycle.
These changes can be detected as a volume pulse.
When does the tissue volume increase during pulse plethysmography?
During systole when arterial inflow exceeds venous outflow.
When does the tissue volume decrease during pulse plethysmography?
During diastole as inflow diminishes and outflow predominates.
What causes the Dicrotic Notch in Pulse plethysmography?
There is often a brief period of retrograde flow in the peripheral arteries during early diastole.
Flow reversal produces the dicrotic notch on the downslope of the volume pulse.
What are 3 other options for testing of arterial disease?
- 1.) DSA
- 2.) 3-d MRA
- 3.) CTA
What does DSA stand for?
What is DSA used for?
What is the limitations of DSA? (2)
Digital Subtraction Angiography
Standard method for preoperative assessment, and gives the precise anatomic informative may be essential in planning reconstructive arterial operations.
- 1.) Bad estimator of hemodynamics of significant stenosis.
- 2.) Only single-plane views
What is the purpose of non-imaging testing of upper arterial system? (3)
- 1.) Presence
- 2.) Severity
- 3.) Location
What are some common indications or reasons for non-imaging testing of upper arterial system? (7)
- 1.) arterial insufficiency
- 2.) thoracic outlet syndrome
- 3.) Raynaud's disease
- 4.) Ischemic ulcers
- 5.) Limb ischemia
- 6.) Follow up Hx of PVD
- 7.) Arterial intervention of the upper extremity
What are the contraindications and limitations of non-imaging testing of upper arterial system? (4)
- 1.) functioning dialysis access graft
- 2.) Recent surgery, ulcers, casts or bandages on the upper extremity
- 3.) Patients with incompressible vessels
- 4.) Patients who are post upper extremity interventional procedure.
What are the steps to upper arterial system non-imaging testing?
- 1.) Obtain PVR's
- 2.) Put BP cuffs on brachial, forearm, wrist.
- 3.) PPG sensor on both 2nd digits (index fingers)
What is the second digit?
the index finger
Where should you start getting upper arterial segmental pressures?
Wrists then forearm then brachial
What are the 4 symptoms of Raynaud's Phenomenon?
- 1.) Fingers and/or toes go numb.
- 2.) Digits turn white due to total lack of blood flow.
- 3.) If the attack is prolonged, digits turn blue and pain sets in.
- 4.) As flow is returned to the digits, the fingers flush deep red, followed by burning and throbbing.
What are the color changes in order of digits in Raynaud's Phenomenon?
What are the 4 nondrug treatments of Raynaud's Phenomenon?
- 1.) Warm hands and feet
- 2.) Quit smoking
- 3.) Remove self from stressful situations and relax
- 4.) Exercise regulary
What are the 3 medication treatments for Raynaud's Phenomenon?
1.) calcium-channel blockers
3.) Nonspecific Vasodilator
What do Calcium-channel blockers do?
relax smooth muscle and dilate the small blood vessels
What do Alpha-Blockers do?
Counter-act the actions of norepinephrine (a hormone that constricts blood vessels).
What do Nonspecific vasodilator do?
Relaxes blood vessels.
Examples: Nitroglycerine paste (which is used to help heal ulcers!
Raynaud's Disease will have an what type of waveform?
Which type of Raynaud's has anacrotic knotch?
Is also known as what?
Which type of Raynaud's has a dampened waveform?
Is also known as what?
Which type of Raynaud's causes the digits to change colors?
Raynaud's Disease or Primary Raynaud's
In response to cold or stress.
Which type of Raynaud's is more serious?
Raynaud's phenomenon or secondary Raynaud's
The presence of cold sensitivity complicated by fixed arterial obstruction.
Who does primary or Raynaud's Disease affect?
more women than men.
approx. 75% is women 15 to 40 years old
What are some causes of the most serious cause of Raynauds? (3)
- 1.) obstructive arterial disease
- 2.) carpal tunnel syndrome
- 3.) connective tissue disease such as sleroderma, systemic lupus erythematosus.
Raynaud's Phenomenon or secondary Raynaud's
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