RVS Part III

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Author:
marie78
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304082
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RVS Part III
Updated:
2015-07-01 22:31:00
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Peripheral Arterial
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RVS Arterial
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RVS Exam Art
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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. Peripheral Arterial Anatomy-LE (CFA)
    • -Originates @ Inguinal Lig
    • -Continuation of the EIA
    • -Courses LAT to CFV & divides→DFA & SFA
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. 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
  26. 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
  27. 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
  28. Peripheral Art-Uncontrollable Risk Factors
    • -Incr age
    • -Family Hx
    • -Male gender
    • -Thrombophilia: hereditary risk toward development of thrombus (Bl clot)
  29. 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
  30. 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
  31. 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
  32. 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
  33. 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
  34. 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
  35. 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
  36. 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
  37. 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
  38. 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
  39. 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
  40. 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
  41. 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
  42. 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
  43. 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
  44. 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
  45. 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
  46. 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
  47. Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po Meas
    • -(UE/LE)
    • -1. RATIONALE: Provides physiologic info & confirm vascular etiology for Claudication & Ischemic Rest Pain
    • 2. CAPABILITIES: 
    • -Screens for presence, level & severity of Atherosclerotic Occlusive Disease
    • -Provides Info for baseline & follow-up treatment
    • -Diff Vascular sx fr Neurologic or Musculoskeletal disorders
    • -Helps diff True Art Disease fr cold sensitivity/Vasospasm of digits
    • -Aids in prediction of wound/ulcer healing
    • -Toe Po <30 mmHg=Poor healing potential
  48. 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
  49. 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
  50. 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
  51. 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
  52. 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
  53. Peripheral Art: Non-Invasive Test Procedures (Indirect Testing) Segmental Systolic Po 
    -Interpretation of Po in UE-
    • -DIFF of 20 mmHg or more betw Brachial Po=Innominate, Subc, Axillary or PROX BA Occlusive disease on the side of the ↓ Po
    • -Po fr wrist & forearm s/b ≥ Brachial Po
    • -↓ in Po of >15-20 mmHg fr wrist/forearm=
    • 1. BA obst DIST to upper arm cuff
    • 2. Obst in both Radial/Ulnar Art
    • 3. Obst in either R/U A (single A); Art w/ ↓ Po
  54. 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
  55. 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
  56. 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
  57. 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
  58. 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
  59. 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 ↑
  60. 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
  61. 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
  62. 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
  63. 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
  64. 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
  65. 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
  66. 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
  67. 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
  68. 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
  69. 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
  70. 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
  71. 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
  72. 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
  73. 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
  74. 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
  75. 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
  76. 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
  77. 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
  78. 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
  79. 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
  80. 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
  81. 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
  82. 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 ↓
  83. 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
  84. 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
  85. 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
  86. 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)
  87. 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
  88. 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
  89. 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
  90. 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
  91. 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
  92. 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
  93. 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
  94. 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
  95. 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
  96. 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
  97. 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
  98. 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
  99. 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
  100. 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
  101. 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
  102. 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
  103. 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

  104. 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

  105. 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 ↓


  106. Peripheral Art: Non-Invasive Test Procedures (DIRECT Testing) Duplex/Color Flow Spectral Doppler Quantitative Interpretation 
    Resistive Index
    -Numerical indicator of Resistance

  107. 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
  108. 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
  109. 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
  110. Peripheral Art: Correlative &/or Prior Imaging DSA
    -Same technique used in Cerebrovascular
  111. 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
  112. Peripheral Art: Correlative &/or Prior Imaging Limitations
    • -Same as Cerebrovascular 
    • -Anaphylactic reaction, renal failure or hemorrhages @ the site of ART puncture are possible risks
  113. 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
  114. 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
  115. Peripheral Art: Treatment
    • 1. Medical Therapy
    • 2. Surgical Therapy
    • 3. Endovascular
  116. 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
  117. 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
  118. 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
  119. Peripheral Art: Treatment Surgical Therapy-Endarterectomy
    • -ART is exposed & surgically opened in the region of Atherosclerotic disease
    • -The Intima, Media & Plaque are surgically removed
  120. Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Prosthetic)
    • -Refers to synthetic grafts:
    • -Dacron, PTFE, Goretex
    • -Used in the Pelvis, Thigh & Above knee
  121. 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)
  122. 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
  123. 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
  124. Peripheral Art: Treatment Surgical Therapy-Bypass Graft (Types of Anastamoses)
    • 1. End-to-side
    • 2. End-to-end
    • 3. Side-to-side
  125. 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
  126. 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
  127. 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
  128. 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
  129. 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
  130. 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
  131. 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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