RVS Part V

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marie78
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304643
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RVS Part V
Updated:
2015-07-01 22:26:03
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Misc Conditions Tests
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RVS
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Vascular Exam
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  1. Preoperative Venous/Art Mapping
    • -Veins
    • -LE: GSV & LSV
    • -UE: Basilic & Cephalic Vns
    • -ART
    • -Radial A
    • -Internal Mammary A
    • -Epigastric A
  2. Preoperative Venous/Art Mapping
    Capabilities & Limitations
    • -Capabilities:
    • -Visualize & measure Length & Diameter of vessel
    • -Document any areas of pathology & anomalies
    • -Limitations:
    • -Presence of wounds, staples or incisions can limit imaging areas
    • -Previous harvesting of vessels may limit the ID of vessel segments
  3. Preoperative Venous/Art Mapping
    Exam Protocols
    • -Saphenous vn mapping determines vn suitability & marks the course of the saphenous vns
    • -Pt Positioning:
    • -Reverse Trendelenburg w/ upper body & head elevated
    • -Sitting w/ leg in a dependent position for ID & marking of perforators & comm vns
  4. Preoperative Venous/Art Mapping
    Technique
    • -Eval PROX Deep Vns to r/o obstruction
    • -Scan the course of Saphenous vns for Patency, Residual thrombus & Duplicate sys
    • -Meas Diameter of GSV @ these locations:
    • -Upper, Mid, Lower Thigh
    • -Upper, Mid, Lower Calf
    • -If GSV is unsuitable, meas LSV @ PROX, MID, DIST locations
    • -If indicated mark the course of Saphenous Vn on skin prior to surgery
    • -If indicated, Perf & Comm Vns s/b ID & marked
  5. Preoperative Venous/Art Mapping
    Interpretation
    • -Normal/adequate for harvesting
    • a. Saphenous Vn diameters of 2.5 mm or >
    • b. Phasic flow
    • -Abnormal/unsuitable for harvesting
    • a. Saphenous vn <2mm or 0.2 cm
    • b. Saphenous vn varicosities
    • c. Perf diameter >3mm=Incompetence
    • d. Perf reflux (retrograde flow) lasting longer than 1 sec.
  6. Radial Art Mapping
    • -Advantages of RA over Saphenous Vn for harvesting:
    • 1. Better availability
    • 2. Thicker medial walls
    • 3. More appropriate vessel diameter
    • -Contraindications
    • 1. Incomplete Palmar Arch
    • 2. Raynaud's syndrome
    • 3. Ischemic digits
    • 4. Stenosed or occluded RA
  7. Radial Art Techniques
    • -PPG w/ compression on RA & UA
    • -Eval digital Art during Alt comp of Radial/Ulnar A to determine Palmar Arch patency
    • -Digital PVR for Palmar Arch testing
    • -Digital Po w/ RA comp
    • -Duplex imaging for vessel diameter, stenosis & occlusion
    • -Eval entire RA for Ca+ segments, Stenosis/Occlusion
    • -Meas diameter in PROX, MID, DIST locations
    • -Meas PSV in PROX & DIST locations
  8. Radial Art Interpretation
    Normal/Vessel adequate for harvesting
    • a. Good perfusion of Bl to the digits fr UA as indicated by PPG, PVR or digital Po
    • b. Diameter meas of @ least 2mm but 2.5 mm or > is preferred
    • c. NO indication of stenosis
    • d. Normal Triphasic flow w/ no turbulence
  9. Radial Art Interpretation
    Abnormal/unsuitable for harvesting
    • -Radial A dominance
    • -Incomplete Palmar Arch
    • -Vessel Diameter <2 mm
    • -Stenotic or Occluded vessel
  10. Pseudoaneurysm
    • -Hole in the Art wall causing Bl to escape & form a pulsating hematoma in tissue around the vessel
    • -Direct: Duplex scanning & color flow imaging
    • -Capabilities: Able to determine a Pseudoaneurysm vs a hematoma (usually an ART puncture Post angiogram or ♡ catheterization)
    • -Limitations: Surgical dressing, wounds, staples or incisions
    • -Pt Positioning: Supine
  11. Pseudoaneurysm
    Sonography-guided Tx comp repair
    • -Locate & meas size of Pseudoaneurysm
    • -Locate comm channel (neck) to the native art 
    • -Tx is firmly comp against skin dir over the neck of pseudo to the point neck is fully comp
    • -Comp is @ 10 min intervals for up to 1 hr
    • -During comp, check pts foot w/ a CWD to ensure ART is NOT being blocked off & that there is a pedal pulse
    • -Comp is contraindicated if:
    • -Pseudo is above Inguinal Lig
    • -Graft Pseudoaneurysm
    • -Pt is on Anticoagulants
  12. Pseudoaneurysm
    Sonography-guided Thrombin Inj repair
    • -Location & size of pseudoaneurysm & location neck to native Art is important to document
    • -Thrombin is inj→body of the pseudo as Bl flows into it
    • -Care must be taken to avoid injecting thrombin→Bl flowing toward the main Art
    • -Thrombosis w/in pseudo is most often instantaneous
  13. Pseudoaneurysm
    Measurements
    • -Pseudoaneurysm diameter
    • -Neck length & diameter
  14. Pseudoaneurysm
    2-D interpretation
    • -Normal:
    • -Single Pseudoaneurysm w/ comm neck to the native Art
    • -Abnormal:
    • -Multilocular Pseudo: 2 or more distinct lumens comm w/ native Art via a single neck
    • -Simultaneous AVF
  15. Pseudoaneurysm
    Spectral & Color Doppler interpretation
    • -Spectral Doppler:
    • -FWD & Reverse flow ('to & fro' flow) w/in the body of the pseudoaneurysm
    • -Color Doppler:
    • -Detects presence/absence of flow w/in fl coll
    • -Determines Dir of flow
    • -Swirling pattern w/in pseudo will show 'yin-yang' appearance (red/blue)
  16. AVF Classification
    • -Abnormal connection betw an ART & a VN
    • -Traumatic:
    • -Most commonly has a Single connection betw an ART & VN
    • -Can occur as a complication of an invasive ART procedure 
    • -Common location to form is betw CFA & CFV due to catheterization procedures
    • -Congenital:
    • -Many small connections betw ART & VNS w/in tissue mass
  17. AVF (2-D Interpretation)
    • -Hematoma may be present
    • -When located close to the ♡, there is ↑ risk of Cardiac failure
    • -Peripheral Fistula is likely to cause Ischemia of the extremity
    • -Diameter & length of fistula will predict the R
  18. AVF (Spectral Doppler Interpretation)
    • -Loss of Triphasic flow in the Art
    • -↑ ART diastolic flow (signal becomes Low R) in the Art PROX to fistula
    • -Turbulence & high Vel jet w/in fistula
    • -BP is ↓ in the DIST Art
    • -Pulsatile Venous flow in PROX Vn
    • -Large Chronic fistula may elevate Venous Po; Incompetent Valves & Retrograde flow may be seen in DIST Vns
  19. AVF Pitfalls of measurement
    -Degree of physiologic change depends on the size & location of the fistula
  20. AVF (Color Doppler Interpretation)
    • -Color shows presence or absence of flow w/in the fistula
    • -Color pixels indicate Dir of flow
    • -Flow Characteristics
  21. Dialysis Access
    Types of Dialysis Fistula or Grafts
    • 1. Brescia-Cimino AVF 
    • -RA to Cephalic Vn (Most common)
    • 2. Straight or looped Synthetic graft
    • -Usually PTFE
    • -ART to VENOUS anastamoses
    • 3. Indwelling catheters
    • -For short-term dialysis access
  22. Dialysis Access
    Direct-Duplex scanning
    • -Capabilities:
    • -Eval Fistula & grafts for defects, stenosis/occlusion
    • -Preoperatively assess ART Inflow & Suitability of efferent Vn
    • -Limitations:
    • -Difficult to examine anastamotic sites bec of graft angulation
    • -Diff to eval the Outflow Vn in Obese pt
    • -Pt Positioning:
    • -Supine w/ arm externally rotated & extended 45o fr the body
  23. Dialysis Access (Exam protocols)
    • -Pre-op mapping of inflow/outflow vessels
    • a. Eval ART inflow (Brachial, Radial/Ulnar A) for intimal thickening, stenosis or occlusion
    • -Eval Venous outflow vessels
    • a. Determine patency of Basilic, Cephalic, Axillary, Subc & Innominate Vns
    • b. Eval for defects, Residual Thrombus, Diameter & Depth fr surface of skin
  24. Minimum Diameter Criteria for AVF & Graft creation
    • Vessel                             Min Diam (cm)
    • AVF Vn                                0.25
    • Graft Vn                              0.40
    • ART (graft or AVF)               0.20
  25. Dialysis Access (Graft Eval)
    • -Eval ART inflow PROX to Graft/Fistula
    • -Eval ART flow DIST to anastamosis
    • -Eval graft @ these locations for Aneurysm, puncture site leaks, Peri-graft fl coll, stenosis or occlusion
    • -Eval outflow vn & entire outflow track
  26. Dialysis Access (Systolic Vel)
    • -Record Systolic Vel:
    • -Native ART PROX to ART anastamosis
    • -ART anastamosis
    • -Graft body @ PROX, MID & DIST locations
    • -Venous anastamosis
    • -Native Vn DIST to Venous anatamosis
  27. Dialysis Access (NORMAL Characteristics)
    • -Flow pattern will be disorganized w/ Spectral broadening
    • -High Flow Volumes
  28. Dialysis Access (ABNORMAL Characteristics)
    • -Stenosis/Occlusion: 
    • 1. No flow in graft
    • 2. No flow in efferent vn DIST to graft/fistula
    • 3. High R in Art PROX to graft/fistula
    • 4. Low Venous Outflow
  29. Dialysis Access (Spectral Doppler Interpretation) NORMAL
    • -Arterial Inflow Art PROX to graft equals Low R, High Diastolic flow
    • -Arterial Art DIST to graft anastamosis equals High R, antegrade flow
    • -Diastolic Vel are significantly elevated w/in patent access grafts/fistulas
  30. Dialysis Access (Spectral Doppler Interpretation) ABNORMAL
    • -High R flow in Inflow A
    • -Stenosis or Occlusion w/in graft/fistula or Outflow Venous track
    • -Most common sites for stenosis are Venous anastamosis & Outflow Vn
    • -Stenosis is usually caused by:
    • 1. ↑ Art Po & flow in Vn (thrombus)
    • 2. Intimal Hyperplasia
  31. Dialysis Access (Spectral Doppler Interpretation) Measurements/Waveform analysis
    • -Normal:
    • -PSV=100-400 cm/s
    • -EDV=60-200 cm/s
    • -Vel ratios:
    • -PSV ratio of 2.0= >50% Diameter stenosis
    • -PSV ratio of 3.0= >75% Diameter stenosis
    • -Flow Vol: mL/min
    • <250=poor dialysis; pending graft failure
    • 300-1000=normal range
    • >1200=possible CHF
  32. Dialysis Access (Pitfalls of meas)
    • -CHF causes ↑ systemic Venous Po
    • a. ↑ in size of IVC & HV seen due to inability of RT Atrium to rcv all of the Venous Ret
    • b. Pts often develop edema in LE due to ↑ Po on the RT side of the ♡ & Venous sys
    • -ART Steal
    • a. Retrograde flow in the Art DIST to the fistula or graft anastamosis
    • b. May result in digit or limb ischemia if collateral pathways are inadequate
    • c. NOT all ART steals are symptomatic
    • d. Digit Po are useful in determining reduced perfusion due to ART steal
  33. Dialysis Access (Color Doppler Interpretation)
    • -Presence/absence of flow w/in the Inflow & Outflow vessels & graft
    • -Dir of flow
    • -Flow characteristics: ↑ in Vel, turbulence or vessel narrowing can indicate Stenosis
  34. Organ Transplants (allograft) Capabilities
    • -Duplex/color flow imaging eval Pre &/or Post-op, Renal & Liver transplants for:
    • 1. Stenosis or occlusion of vessels
    • 2. Signs of transplant rejection
    • 3. Abnormal fl collections
  35. Organ Transplants (allograft) Limitations
    • -Bowel gas overlying the vessels or transplant
    • -Depth of penetration (obese pt)
    • -Scar tissue
    • -Shortness of breath or rapid respirations
    • -Types:
    • 1. Kidney
    • 2. Liver
  36. Organ Transplants (Renal allograft) Exam Protocol
    • -Transplanted Kid will be located subcutaneously in the pelvic region
    • -Native Kid is NOT removed @ time of transplant
    • -Procedure:
    • -Pt Supine
    • -Meas Kid length (pole-to-pole)
    • -Allograft enlarges over a per of mos & should NOT be considered a sign of rejection
  37. Organ Transplants (Renal allograft) Imaging Protocol
    • -Eval Renal transplant in Longitudinal & TRV for:
    • 1. Hydro
    • 2. Perinephric fl coll: hematoma, abscess, Urinoma, Lymphocele
  38. Organ Transplants (Renal allograft) Indications for Rejection
    • -↑ in Renal Vol
    • -↑ in Cortical Echogenicity
    • -↑ Prominence of Renal Pyramids
    • -Cortical Hypoechoic regions (edema, hemorrhage, infarction)
    • -↓ echogenicity of Renal Sinus
    • -↑ flow R in Parenchymal Art
  39. Organ Transplants (Renal allograft) Measurements
    • -Obtain PSV/EDV meas fr:
    • -AO
    • -CIA
    • -IIA or EIA
    • -Donor RA
    • -EIV
    • -Anastomotic sites
    • -Donor RV
    • -Allograft Vessels
  40. Organ Transplants (Renal allograft) Doppler Waveforms
    • -Obtain Doppler waveforms of Parenchymal flow & Calc a RI & PI fr:
    • -Segmental A
    • -Interlobar A
    • -Arcuate A
  41. Organ Transplants (Renal allograft) Spectral Doppler Interpretation
    • -Normal flow:
    • -Vel= 80 - 118 cm/s
    • -Vol flow=346 - 422 mL/min
    • -Parameters for Stenosis exceeding 50% or 60% ↓ in diameter:
    • -PSV >190 cm/s w/ PST
    • -PSV ≥ 250 cm/s
    • -Systolic Vel ration > 3 w/ PST
    • -Ratio of PSV fr stenotic area to EIA PSV
  42. Organ Transplants (Renal allograft) Doppler features of Allograft Rejection
    • -High R waveform 
    • -Sharp, narrow systolic peaks
    • -Second Systolic peak higher than the first
    • -Minimal or absent Diastolic flow
    • -Flow reversal early in Diastole
    • -PI ≥ 1.8
    • -RI ≥ 0.7
  43. Organ Transplants (Liver allograft) Preoperative Assessment
    • -Document patency of the:
    • 1. PV
    • 2. SV
    • 3. SMV
    • 4. HV
    • 5. IVC
    • 6. HA
    • -Assess Liver parenchyma for masses
    • -Eval the Biliary tree
  44. Organ Transplants (Liver allograft) Postoperative Assessment
    • -Document patency of the:
    • *Same as Preoperative Assessment
    • -Normal PV flow=HEPATOPETAL
    • -Size is ≤ 1-1.5 cm
    • -Asses location for abnormal fl collections:
    • -Hematoma, Abscess, Biloma, Ascites, Seroma
  45. Organ Transplants (Liver allograft) Postoperative Complications
    • -Allograft rejection:
    • a. Heterogeneous echo pattern w/in liver
    • b. ↓ in Liver echogenicity
    • c. Poorly defined Liver margins
    • d. ↑ in Periportal Echogenicity
    • -Pseudoaneurysm @ the anastamosis sites
    • -Hepatic infarction
    • -Thrombosis of the PV, IVC &/or HA
  46. Organ Transplants (Liver allograft) Pitfalls of meas
    • -It is difficult to obtain proper Doppler angle in the HA due to its location
    • -Best to obtain a Doppler meas in the PROX HA as it branches fr the CA
  47. Impotence Testing- PBI
    • -Determines if ART Po is sufficient for erection
    • -Can NOT determine other Vascular etiologies of erectile dysfunction
    • -Obtain Brachial & Ankle Po and Calc bilat ABI
    • -An Abnormal ABI=Aorto-Iliac dis resulting in abnormal Penile Perfusion & erectile dysfunction
    • -Calc Penile to Brachial Index (PBI)
  48. Impotence Testing- PBI Interpretation
    -Use a 2.5 x 9 cm penile Po cuff & a CWD

    • -Normal PBI= <0.75
    • -Marginal= 0.65-0.74
    • -Abnormal=<0.65 (indicates Penile Art Insuff)
  49. Impotence Testing- Pre Inj Interpretation
    • -Normal diam meas of cavernosal Art is 0.5 mm
    • -Bl flow in cavernosal Art s/b High R
  50. Impotence Testing- Post Inj Interpretation of Normal Values
    • -PSV & EDV will ↑ (Low R)
    • -PSV >35 cm/s, EDV <5 cm/s during erection
    • -75% or > ↑ in diam of cavernosal Art
    • -Deep Venous flow normally does NOT ↑
    • -Normal Venous flow=<3 cm/s
  51. Impotence Testing- Post Inj Interpretation of Abnormal Values
    • -PSV 25 - 29 cm/s=Marginal Art Inflow
    • -PSV < 25 cm/s= Insuff Art Perfusion
    • -PSV >35 cm/s, but EDV is >6 cm/s suspect Venous leak
    • -Vessel Diameter ↑ is <75%
  52. Thoracic Outlet Syndrome (TOS)
    • -Comp (impingement) of the Subc A @ the Thoracic Outlet by the Scalenus muscle, Cervical Rib (1st rib) or the Clavicle
    • -Can be caused by:
    • 1. Subc A passing betw the ANT & MIDDLE Scalene muscles
    • 2. Subc A passing betw the 1st rib & clavicle
    • 3. Presence of an additional rib-cervical rib
    • 4. ↑ scar tissue due to previous inj
    • 5. Can be completely neurogenic due to compression of the brachial plexus-90% of cases
    • -Art is compressed when Arm is in certain positions
  53. Thoracic Outlet Syndrome (TOS) 
    Signs & Sx
    • -Sensory changes such as 'pins & needles' in hands
    • -Pain
    • -Hand weakness
    • -May see hand & limb atrophy
    • -Arm becomes cyanotic in certain positions
  54. Thoracic Outlet Syndrome (TOS) Noninvasive Test Procedures
    • -R/O Subc A Comp as cause of pt sx
    • -PPG waveforms may 'flatline' when arm is raised over head in some positions
    • -Normal exam cannot R/O TOS completely, only that sx are NOT being caused by Vascular compression
  55. Thoracic Outlet Syndrome (TOS) Indirect
    • -Use of PVR, PPG
    • -Pt s/b sitting erect w/ hands resting in lap
    • -Procedure:
    • Perform a baseline resting physiologic exam of the UE
    • -Pt Hx, CWD, Segmental Po, PVR
    • -Attach PPG sensor to Index finger & monitor Radial A
    • -Obtain PPG waveforms while pt: 
    • -Is resting w/ hand in lap
    • -Arm @ 90o angle (straight out @ side)
    • -Arm in 180o angle (straight above head)
    • -Arm in an exaggerated military 'salute'
    • -Document PPG waveform in any position that brings on pts sx
    • -Perform PPGs Bilat
  56. Thoracic Outlet Syndrome (TOS) Adson Maneuver
    -While taking a deep breath & hands in lap, pt turns their head & extends their neck as far as possible to the RT & then LT side
  57. Thoracic Outlet Syndrome (TOS) Interpretation
    • -Normal:
    • -Amplitude of waveform should NOT change or remain similar in any arm position
    • -Abnormal:
    • -A damping in Systole will signify a partial compression
    • -Total loss of the signal or damping to an almost straight line will signify complete compression
  58. Thoracic Outlet Syndrome (TOS) Direct-Duplex sonography
    • -Pt in Supine position
    • -Subc A s/b examined fr the Supraclavicular & Infraclavicular fossa
    • -Eval Subc A for Plaque, thrombosis, stenosis or occlusion
    • -Observe for narrowing of vessel during various arm positions
    • -Obtain PSV in Subc A w/ arm in various positions
  59. Thoracic Outlet Syndrome (TOS) Direct-Duplex sonography w/ Color Flow Imaging (CFI)
    • -Using CFI, document Subc A, in various arm positions:
    • -W/ arm in Neutral position
    • -W/ arm fully abducted & hand drawn towards back of pts head
    • -W/ hand placed completely behind head
    • -Apply gentle Po to the arm to push it backwards
  60. Thoracic Outlet Syndrome (TOS) Direct-Duplex sonography Interpretation
    • -Normal:
    • -Triphasic flow w/ PSV betw 70 & 120 cm/s
    • -Vel should NOT change w/ position change, but flow pattern may change fr triphasic
    • -Abnormal:
    • -An impingement on the Subc A will show a ↓ Vel as well as color Aliasing in the area
    • -TOS may cause thrombosis, fibrosis & aneurysm of the Art
  61. Median Arcuate Ligament Syndrome
    • -Partial or complete compression of the CA origin by the Arcuate Ligament of the diaphragm
    • 1. Acruate Lig crosses ANT to the AO just SUP to the CA
    • 2. Upon Expiration, the Lig intermittently compresses the CA as it slides over it
    • 3. Sx vary making diagnosis difficult
  62. Median Arcuate Ligament Syndrome-Spectral Doppler Interpretation
    • -During Expiration
    • 1. Vel in the CA will ↑ suggesting a flow reducing stenosis
    • 2. Luminal diameter of the CA is compressed
    • -During Inspiration
    • 1. Vel will immed ↓ (normalize) as the Median Arcuate lig slides off the CA & compression is released
    • 2. Luminal diameter of the CA is restored to normal
  63. Arteritis-Giant Cell
    • -3 types:
    • 1. Cranial (Art of face, head & Post Cereberal circulation)
    • 2. Large Vessel (axillary & subc)
    • 3. Aortic (Aneurysmal degeneration of Ascending AO & AO Valve insufficiency)
  64. Temporal Arteritis (Cranial form)
    • -Autoimmune disorder
    • -Long segment steoses, occlusion or aneurysms of Superficial Temp & Facial A
    • -Can involve Ophthalmic A leading to Retinal Ischemia
    • -Inflammation of ART wall often resulting in thrombosis w/in the vessel
    • -Commonly seen in Elderly White Females
  65. Temporal Arteritis (Cranial form) Sx
    • -Polymyalgia
    • -Rheumatica
    • -Malaise
    • -Elevated Sedimentation Rate (ESR)
    • -Headaches
    • -Focal Temporal Pain
  66. Temporal Arteritis (Cranial form) U/S appearance
    • -Inflammation of vessel wall causes an abnormal 'Halo' appearance around vessel
    • -Stenosis will have ≥ two-fold ↑ in PSV & PST
    • -Always do BILAT study
  67. Temporal Arteritis (Cranial form) Diagnosis
    • -Difficult diagnosis
    • -Must meet 3 of 5 criteria:
    • -Age ≥ 50 y/o
    • -New headache
    • -Temporal Art abnormality on physical exam
    • -Elevated ESR ≥ 50 mm/hr
    • -Abnormal Temporal Art biopsy
  68. Temporal Arteritis (Cranial form) Treatment
    • -Steroidal Therapy
    • -Surgical bypass: contraindicated when disease is in active state
  69. Takayasu Arteritis
    • -Inflammatory process of Tunica Media secondary to collage-related disorders
    • -Originates @ the AO Arch & progresses outward
    • -May affect Subc A
    • -Frequently seen in young Asian females
    • -Diminishing pulse over a period of time
  70. Takayasu Arteritis- Signs & Sx
    • -Malaise
    • -Myalgia
    • -Fever
    • -Night Sweats
    • -Anorexia
    • -Wt loss
  71. Takayasu Arteritis-Assessment findings & Treatment
    • -U/S may show thickening of Subc A
    • -Segmental Po may show ↓ Brachial systolic Po
    • -PVR waveforms may be abnormal
    • -Treatment:
    • -Steroidal Therapy
    • -Surgical bypass-contraindicated when dis is in active state
  72. Radiation Arteritis
    • -2ndary to radiation exposure:
    • a. Neck
    • b. Breast/axilla
    • c. Thorax/mediastinum
    • -Involves Subc & Axillary A
    • -Leads to critical Limb Ischemia
    • -Treatment difficult due to radiation inj
    • a. Autogenous Vn bypass possible
  73. Trauma/ART injury-Capabilities
    • -Eval vessels for damages occured fr blunt or penetrating trauma to vessel such as:
    • -Acute occlusion
    • -Thrombosis
    • -Stenosis
    • -Pseudoaneurysm
    • -Hemorrhage
    • -Hematoma
    • -Absent distal pulses
    • -Intimal flaps
  74. Trauma/ART injury-Limitations
    • -Depending on severity of inj, vessel evaluation may be difficult due to hemorrhage or hematoma
    • -Open wounds or dressings make access to vessel difficult
  75. Trauma/ART injury- Indir Testing (CWD, Plethysmography)
    • -Allows meas of systolic BP in affected extremity
    • -Limitations:
    • -Can NOT be used where extensive wounds prevent placement of pneumatic cuff on extremity
    • -Can NOT diff betw: Intrinsic Art Lesion, Extrinsic Comp or Vasospasm
    • -Distal limb Po measurements cannot detect inj to nonaxial Art
  76. Trauma/ART injury- Dir Testing (Duplex U/S w/ Color Flow Imaging)
    -Used mainly as a screening & ff up in suspicion of ART inj
  77. Lymphedema
    -Obst w/in the Lymphatic sys causing an accumulation of extracellular fl & protein w/in the subcutaneous tissue & skin
  78. Lymphedema-Classification
    • -Congenital or primary: Vascular dysplasia in utero
    • -Acquired or secondary:
    • Malignancy, Radiation, Surgery, Pyogenic infection, Trauma
  79. Lymphedema-Symptoms
    • 1. Limb swelling (starts on dorsum of the foot)
    • 2. Heaviness
    • 3. Recurrent Lymphangitis
    • 4. Skin Changes
    • 5. Fungul infections
  80. Lymphedema-Physical Findings
    • 1. Nonpitting limb edema
    • 2. Dorsal 'buffalo hump'
    • 3. Elephantine distribution of tissue/fl
    • 4. Flushed skin color
  81. Lymphedema- 6 primary causes of Edema
    • 1. Sustained ↑ in capillary Po
    • 2. ↓ in plasma oncotic Po
    • 3. ↓ in tissue Po
    • 4. ↑ in capillary permeability
    • 5. Lymphatic obstruction
    • 6. Dilation of the pre-capillary sphincters
  82. Lymphedema- Other causes of Edema
    • -CHF
    • -Venous outflow obstruction
    • -Cirrhosis
    • -Kidney failure
    • -Venous Insufficiency
  83. Lymphedema- Treatment
    • -Elevation of affected limb(s)
    • -↑ of external Po w/ either massage or tight hose/stockings
    • -↑ in Bl albumin levels to ↑ osmosis
    • -Resolve cause of obst

    *Acute Lymphedema is like other edemas in its response to treatment
  84. Chronic Lymphededma
    • -Lymphedema lasting over 1 year
    • -Edema becomes non pitting
    • -Elevation & external Po ↓ ability to relieve edema
    • -Skin becomes thickened, dimpled, 'woody,' 'pig-skin/football-ish'
    • -Does NOT have a tendency toward Venous ulceration
  85. Sonographically-guided procedures
    • -Biopsy
    • -Thrombin inj of pseudoaneurysm
    • -Tx compression therapy for pseudoaneurysm
    • -Intraoperative surveillance of vessels
  86. Intra-operative Duplex Assessment: ART repair
    • -2 methods:
    • 1. Open surgical
    • 2. Angioplasty or stenting
    • -Duplex is typically performed after the ART repair & prior to incision closure or removal of catheter for angioplasty procedures
    • -Vessels eval: Carotid, UE/LE, Visceral ART
  87. Intra-operative Duplex Assessment: ART repair (Tx considerations)
    • -Flat Linear (w/ small footprint)
    • -10-15 MHz for open surgical w/ Dir placement of Tx on vessel wall
    • -5-8 MHz for pre or post angiography assessment (Best F for optimal Res)
    • -Tx is inserted in a sterile plastic sleeve filled w/ gel
    • -Saline is used as the couplant betw Tx  & Vessel for open incision repair in operative wound
  88. Intra-operative Duplex Assessment: ART repair (Role of Sonographer)
    • -Select appropriate Tx
    • -Assist w/ Sterile technique
    • -Image vessel in both TRV & SAG planes
    • -Optimize B-mod & Color Doppler
    • -Obtain Doppler Vel w/ vessel in Long axis & incident angle ≤ 60o
  89. Intra-operative Duplex Assessment: ART repair (Eval B-mode, color, & Spectral Doppler of)
    • -Inflow
    • -Attachment site (PROX)
    • -Reconstructed segment (PROX, MID, DIST)
    • -Attachment site (DIST)
    • -Outflow/runoff
    • -Compare results & Vel to prior exams
  90. Intra-operative Duplex Assessment: ART repair (Abnormalities)
    • -Cause for Post Procedural stenosis:
    • 1. Residual plaque
    • 2. Suture stenosis
    • 3. Kink
    • 4. Clamp inj
    • 5. Dissection
    • 6. Anastomotic
    • 7. Entrapment
    • 8. Stent Fractures
    • -Thrombus
    • -Inadequate runoff
  91. Intra-operative Duplex Assessment: ART repair (Abnormal Hemodynamics indications)
    • -Elevated PSV &/or EDV
    • -PST
    • -Absent diastolic flow
    • -Reperfusion syndrome or spasm=High Peak & End Diastolic flow
  92. Intra-operative Duplex Assessment: Venous Ablation
    • -Minimally invasive & non-surgical technique to treat Venous Insufficiency or Varicosities
    • -Treatment is thru creation of a thermal inj to the Venous luminal wall w/ a sequelae of thrombosis that seals off Vn
    • -Radio(F) or Laser Fiber (more curr technique) are utilized for Ablation
  93. Intra-operative Duplex Assessment: Venous Ablation (Vns compatible)
    • -GSV
    • -LSV
    • -Accessory branches
    • -Perforator Vns
  94. Intra-operative Duplex Assessment: Venous Ablation (Sonographic imaging)
    • -Document incompetent Superficial Vns, junctions, Varicosities & Perforators w/ B-mode, color & Spectral Doppler
    • -Meas GSV & LSV diameters
    • -Confirm non saphenous sources for varicosities
    • -Note Depth of Saphenous Vns
    • -Assess Deep Venous Sys for DVT
  95. Intra-operative Duplex Assessment: Venous Ablation (Treatment Procedure)
    • -Physician performing procedure may hold Tx and perform imaging w/ sonographer operating controls on equipment
    • -Sonographer performs imaging & duplex assessment during procedure
  96. Intra-operative Duplex Assessment: Venous Ablation (Sonographic imaging assessment)
    • -Pre scan: Document presence or absence of changes since pre-assessment vn mapping
    • -Venous access:
    • -CTR vessel in cross-section
    • -Optimize for Max image quality
    • -Access is gained
    • -Confirm wire placement in Long axis fr insertion to desired point
    • -Confirm tip of laser fiber is @ least 2 cm fr junction
  97. Intra-operative Duplex Assessment: Venous Ablation (Sonographic imaging-Tumescent Anesthesia)
    • -Confirm fl above vn containing sheath & laser fiber
    • -Confirm Vn is surrounded by fl & is collapsed
    • -Ablation:
    • 1. FF movement of laser tip as it is pulled back
    • 2. Visualize steam bubbles to verify laser firing
    • -Verify Vn closure
    • -Assess venous junction to confirm absence of thrombus extension→deep vns
  98. Intra-operative Duplex Assessment: Venous Ablation (Sonographic imaging Post procedure)
    • -Assess LE for DVT
    • -Verify Vein closure
  99. Intravascular Ultrasound (IVUS)
    • -Miniature Tx is positioned @ tip of an Intraluminal catheter
    • -F range is usually 20 MHz or higher
    • -Provides high resolution vessel imaging of lumen, vessel wall, & lesion morphology
    • -Assists in decisions for the most appropriate intervention option

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