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137 Cards in this Set
- Front
- Back
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what arteries supply collateral circulation?
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-lumbar
-MCA -SMA |
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where is the transducer placed for duplex imaging of the aorta?
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-just below the xiphoid process
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where is the aortic bifercation best seen?
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when the patient is laying on their left side
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explain the anatomy of the anterior and inferior illiac arteries
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ANT:
-unbilical obterator -internal pudendal -inferial gluteal POST: -illiolumbar -lateral sacral -superior gluteal |
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explain the procedure for examination of lower extremity arteries
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-examine to the level of the groin using 2D, color, and spectral doppler
-turn decub to evaluate internal and external illiacs -waveforms w/ peak and end-diastolic measurements should be obtained at the points of bifercation and mid vessel -transverse used if flow abnormalities or aneurysm is suspected |
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what artery arises off of the superficial femoral artery? what is a normal varient of the superficial femoral artery?
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-the genicular artery arises from the SFA
-normal variant=duplication of suprficial femoral artery |
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when does the anterior tibial become the dorsalis pedis? What are some normal variants of the dorsalis pedis?
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-after crossing the ankle
NORMAL VARIANTS: -4-12% of patients have hypoplasia, or aplasia, so there is an absence of a DP pulse -atyplical location occurs in 8% of population |
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where does the peroneal artery lie in relation to the posterior tibila arterY?
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-lies deep and runs parallel to the posterior tibial artery
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what are the normal varients of the poterior tib, and peroneal arteries?
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-absent posterior tibial artery(5%)
-peroneal artery arising formt he anterior tibial artery |
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what are the most common sights of atherosclerosis development in the lower extremity?
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-aortic bifercation
-common iliac bifercation -common femoral bifercation -segment of SFA in hunter's canal(most common) -popiteal artery bifercation |
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if stenosis is seen w/ b-mode /or color, what should be done?
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-obtain spectral waveforms from the prestenotic, stenotic, and post-stenotic regions
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how is color properly optimized?
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-color steering
-color Frame rate -color gain -color scale |
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when is a stenosis considered hemodynamically significant?
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-when the sumen is reduced by 75% or the diameter is reduced by 50%
-stenosis that produces a severe decreae in pressure and flow. |
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what happens to blood flow w/ an increase in the number of stenotic lesions?
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-blood flow is increasingly limited
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w/ishemia, what may happen to arterioles?
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-they may remain dialated in order to allow more blood flow to tissues, resulting in a monophsic waveform
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what happens to the velocity, and flow of blood pre, during, and post-stenosis?
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-proximal-damped velocities
-at entrance, through and exit-increase in velocity; disorganized flow -at exit-post stenotic turbulence |
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what is the lower extremity abnormal PSV at a stenosis, and compared to prestenotic PSV
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2:1=>50%=200cm/sec
4:1=>75%=400cm/sec |
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what are the capabilites and limitations of duplex imaging?
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CAPABILITIES:
-can indicate exact location of disease, and determine stenois vs. total occlusion -useful to detect and differentiate aneurysms, pseudo-aneurysm, hematoma, and graft patency LIMITATIONS: -time consuming -requires skill -calcium may obscure artery making disease location difficult -bandages/casts lead to limited visualization |
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where is the most common peripheral arterial aneurysm located? what symptoms will occlusion of this cause?
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-popiteal artery aneurysm
-sympotms of acute ishemia w/ occlusion -usually bilateral |
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when do femoral pseudo-aneurysms usually occur?
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-following arterial punctures from antiography or angioplasty
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what is normal when comparing bypass graft ?
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-it is a normal finding to observe retrograde flow into the bypassed segment of the native artery due to decreased pressure
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compare dulex vs. arteriography
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DUPLEX:
-harmless -painless -inexpensive -no biological effects -time consuming -requires skill -calcium may obscure plaque -patient factor ARTERIOGRAPHY: -invasive -painful -relatively expensive -associated w/ some morbidity |
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when does the PSV decrease?
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-w/ increasing age, and as you go distally in the body
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what is an abnormal SFA acceleration time?
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>144m/s
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in lower extremity arteries, a diameter reduction >50% results in:
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-dropped pressure and flwo(removed energy)
-leds to the development of intermittent claudication -visualization of triphasic waveform=highly unlikely that high grade stenosis may be proxiaml to the site -need to perform stress test to determine disease |
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if you have a stenosis, the comparasin of velocity is made where in relation to the stenosis?
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the comparasin of velocity is always made to the segment immediately proximal to stenosis.
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name and explaint the categories of stenosis, their percentages, waveforms, spectral broadening, and PSV
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NORMAL:
-0% stenosis -no plaque on walls -triphasic waveform MILD: -1-19% steosis -triphasic waveform -some spectral broadening -PSV is less than double that of closest prox normal segment MODERATE: -20-49% stenosis -PSV less than double that of closest prox normal segment -marked spectral broadening -may be biphasic due to attenuated reverse component SEVERE: -50-99% stenosis -increased systolic velocity by>100% -PSV douple the proximal adjacent segment(>200cm/sec) -marked spectral broadening -Reverse flow component is absent NEAR OCCLUSION: ->80% -flow dininishes and waveform becomes damped -reverse flow component is absent TOTAL OCCLUSION: -no flow -systolic thumping prox to occusion -collateral re-entry distal to occlusion identified by a low velocity, monophasic flow pattern w/ spectral broadening |
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In lower extremeity arteries, what does a diamter reduction>50% resut in?
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-a drop in pressure and flow(removes energy), and leads to the development of intermittent claudication
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how can stenotic lessions that do not effect flow patterns be important?
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if the flow incraeses, they can become hemodynamically significant as w/ exercize.
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what diameter reduction corrilates w/ claudication? explain
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>50% diameter reduction corrilates w/ claudication
-there is no need to bread down the diameter reuction btw 50-99% |
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where is the velocity taken in multisegmental disease?
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immediately proximal to the stenotic segment
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give percent stenosis, PSV for each type of stenosis
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normal-PSV <150
30-49%-150-299cm/sec 50-75%-200-400cm/s >75%=>400cm/sec occlusion-no color saturation |
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Arterio-liliac inflow system; what is it, know where it is on a diagram
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-refers to major vessels supplying blood to the arteries of the lower extremity
-extends from aorta @ renal artery level to inguinal ligaments of each leg and includes the common and external iliac arteries -if there is obstruction at this site, there is limited blood supply to either or both legs. -this is the second most common site for atherosclerotic disease of the lower extremity |
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explain femoral popiteal outflow systme
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-from inguinal ligments to the upper leg at the level of the popiteal artery trifercation
-called an outflow system because it receives outflow from the aorto-illiac arteries transporting blood to run-off system -contains vessels w/ the highest incidence of lower extremeity arteries disese(SFA at hunter's canal) |
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tibial peroneal run-off system
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-starts at the termination of the popiteal artery and extends to the level of the ankle
-receives runoff blood from both systems above -even w/ total occlusion of SFA, flow can be identified in this system because of collateral flow by the profunda artery -occlusion to CFA-no flow in tibioperoneal run off system becuse both SFA and profunda receive no flow |
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what happens w/ occlusion to CFA?
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no flow in tibioperoneal run-off system because both SFA and profunda arteries revceive no flow
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compare duplex imaging to arteriogrphay
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DUPLEX:
-harmless -painless -inexpensive -to biological effects -provieds hempdynamic as well as anatopic info -cn predict graft failure -suitable for screening patients -valuble for following patients after surgury ARTERIOGRAPHY: -invasive -painful -relatively expensive -associated w/ morbidity because of harmful radiation -Provides anatopical inforation only -cannot predict graft failure -not suitable for screeenign patiens -not practical for post-surgical follow-up of patients |
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velocimetry
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method of assessing location and semiquantitative severity of disese
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what do the horizontal and verticle axis's on spectral doppler represent?
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time=horizontal
frequency shift=verticle |
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what probe is used for indirect physiologic testing?
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4 or 8 mHz
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what are some ways to quantitiate a doppler waveform?
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-PI-independant of angle; increases from prox to distal(peak to peak/mean height)
PI of CFA of >6 in normal without SFA disease, a PI <5 indicates aorto-illiac disease -acceleration time =>144cn=abnormal----from onset of systole to peak velocity; increase indicates proximal disease -acceleration idex-change in PSV-onset SV/accel time AI<3.78kHz=abnormal |
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name and explain the types of doppler evaluations:
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ANALOG DOPPLER:
-displays doppler waveform on a strip chart recorder or electronically on a monitor display -displays a single-line trace of the averge freqency shift SPECTRAL WAVEFORM: -displays individual frequencies using FFT method -time is shown on horizontal axis, velocity shift on verticle axis |
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how should the patient be positioned for peripheral arterial non-invasive tests?
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-basal state
-supine w/ extremities at the same level as the heart -lower extermity requres hip rotated, and knee slightly bent |
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what upper extermity waveforms are obtained for peripheral arterial non-invasive tests?
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-subclavian artery, axillary, brachial, ulnar, and radial arteries
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explain the qualitative assesment of peripheral arterial-non-invasive tests
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-triphasic is normal, and it changes to monophasic as disease progresses
-monophasic waveforms can be seen both proximal and distal to an obstruction -observe deterioration of a signal from one sement to the next |
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what is the major limitation of peripheral arterial non-invasive testing
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-inability to locaize specific segment of diesease
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peripheral arterial exercise testing
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when a patient presents w/ claudication and has a normal rest study, it is necessary to test the patient w/ exercise to reproduce his/her symptoms
-this should induce peripheral vasodialtion in the microcirculation so that distal peripheral reistance decreases and flow increases |
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explain the technique for exercise testing
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-treadmill is at 1.5-2mph w. 10 degree elevation for max of 5 minutes or until symptoms prevent the patient from continuing.
-immediately following exercise, obtain pressures from both ankels, and the arm, so ABI's can be calculated -arm w/ the highest brachial pressure is used -post exercise ankel pressures should be monitored for upto 10 minutes until to pre-exercise pressures are readched |
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how should exercise testing be interpretated?
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NORMAL: pressures stay the same or show a slight increase
ABNORMAL-pressures decrease during and after exercise a)single level disease-pressures return to normal within 2-6 minutes b)multi level disease-pressures remain decreased for 12 or more minutes c)after exercise, ankle pressures below 60mmHg confirm a vascular etiology for claudication |
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what are the capabilities of exercise testing?
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-differentiate btw true claudiation and pseudoclaudication
-help determine presence or absence of collaterals |
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which patients should not be exercised on the treadmill?
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-questional cardiac condition
-severe hypertension -poor ambulators -ishemic rest pain or ABI<.0 -COPD |
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What is used in place of treadmill testing when patients cant' tolerate walking?
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reactive hyperemeia or
-toe raises may be substitueded for treadmill and reactive hyperemia in symptomatic patients that cannot ambulate. |
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explain the patient postion, and technique for reactive hyperemia?
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Patient postion-supine w/ thigh cuffs applied
Technique-thigh cuffs are inflatted to occlude flow and are maintained for 3-5 mintues -ankle and brachial pressures are obtained after cuff deflation |
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HOw is reactive hyperemia interpreted?
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-pressure drops in diseased libs are similar to those after treadmill testing
-single level disese=<50% pressure drop -multi-level disease=>50% pressure drop |
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what are the limitations of reactive hyperemia?
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-poor patient tolerane due to pain
-does not simulate walking |
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PVR
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pulse volume recodint(aka segmental air plesmography)-measures a cnange in dimention of a limb or body part in response to a change in blood content
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plesmography
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to recod an increase;records the diffeence in volume of a cuff; can be measured by:
-volume -circumference -electrcal imepednce -light relfectance |
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plesmograph
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pressuer transducer connected to a strip recorder
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what is the most valuble feature of PVR?
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is not affected by calcified vessels; this is a better test than Segmental pressure testing when there is significant arterial calcification and arteries are difficult to occlude w/ segmental pressure testing
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what is the PVR technique?
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-inflate thigh cuff to 65mmHg with a volume of 400+-75CC
-inflate calf and ankel cuff to 65mmHg w. a volume of 75 +-10CC of air |
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explain assessment of the PVR waveform?
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-Normal-sharp upstroke; dicrotic dotch on downstroke
-mildly abnormal-sharp upstroke; absent dicrotic dotch downward; slope bowed away from waveform -mod. abnormal-round systolic peak; downstroke nearly equal - |
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Where is disease detected w. PVR?
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proximal to the cuff used
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what are the limitations of PVR?
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-edema, tremor, A-fib, distal disease, warm room have to haev tension on cuff
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strain guage plesmography
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-measures circuference
-alternative to CW and PVR -based on electrical impedence -qualitiative, not quantitative |
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explain the procedure for SPG
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-aka strain guage plesmography
-patient in warm room -silastic band -measures a change in circumference by sending an electrical pulse through a limb |
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photoplesmography
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(PPG):
-2 crystals -one emits infared light, and the other recieves reflected light -produces an analog waveform -not a true plethysmograph -excellent for digital profusion |
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explain the technique for PPG
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-warm room
-sensor applied to distal extremity -arterial waveform recorded on a strip chart |
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waveform for PPG
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-normal-sharp systolic upstrok; dicrotic notch
-occlusion-decreased amplitude, rounded peak -loss of dicrotic notch; decreased or absent in diastole |
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pseumo-plethysmography/air plethysmography
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known as PVR(pulse volume recording, pulse cuff recording, or volume pulse recording
-records a volume change in a limb related to pulsisitle arterial flows -usual type of recording device is a PPG -PPG uses transmitted and reflected infared light to record cutaneuous blood flow |
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what is the patient postioning for PVR?
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upper extremity-patient supine w/ arms at side
lower extremity-supine w/ legs at same level as heart |
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Explain the technique for peripheral arterial plethsymography?
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TOES:
-toe cuff 1.2 times the toe size(2.5-3cm) -records waveforms FINGERS: =-assess digits w/ PPG for resting arterial profusion(2-2.5cm cuff) FINGERS w/ COLD STRESS: -imerse hands in ice water for 3 minutes -obtain waveform immediately and 5 minutes after |
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explain how peripheral arterial plethysmography is interpreted?
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-normal-waveform has sharp upslope in systole; prominent reflected wave in diastole; refelctive or dicrotic notch
-Mildly abnormal-waveform lacks reflected wave and shows a slight loss of amplitude -MOderately abnomal-waveform has flattened systolic peak, loss of reflected wave, and reduced rise in systole |
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what may occur to the waveform w/ patients w/ raynaud's syndrome?
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peaked waveform in the digits. the amplitude of the wavefor is greater in the fingers than in the toes
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what are the capabiliteis of plethsymography?
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-definig vascular etiology for digital symotms including blue toe syndrome
-differentiate small vessel atherosclerotic disease from vasospastic disorder |
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what are the limitations of plethysmography?
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-significant prozimal arterial disease may reduce digital profusion causing a near flat line waveform which eliminates the ability to evaluate digits from small vessel arteries
-in cold climates, patients may present w/ normal vasoconstriction of digital arteries(extremities should be warm before plethysmographic evaluation) |
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IN a normal patient, how does the ankle systolc presure compare to the brachial pressure? what normally happens to the peak systolic pressure as you move down the leg?
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-ankle systolic pressure should be higher
-peak systolic pressure is amplified as you move down the leg. |
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what should the cuff size w/ segmental pressure testing be?
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cuff size bladder should be 20% wider than the diameter of the limb for accuate pressure reading
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explain the 3-cuff technique?
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-17X40 cm cuff on thigh(often contour)
-12X40cm cuff below knee, and at akle -10X40 cuff at the ankle; |
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4 cuff technique
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12X40 cuffs placed around upper thigh, lower thigh, below knee, and ankle
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what is the drawback to the 4-cuff technique?
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-falsely elevated high thigh presure due to narrow cuff size compared to limb girth
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what is the size of the toe cuff in relation to toe size? what size is this?
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1.2 times the toe size(2.5-3cm)
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which artery is used for segmental pressure testing?
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-CW probe is placed over the dorsalis pedis or posterior tibial, and the artery w/ the highest reading will be used for the rest pressure.
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explain how segmental pressure testing is interpretated?
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ABI:
normal->.95 single segment disease=.5-.9 multi-segment disease=<0.5 associated w/ rest pain=<0.3 |
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how is ABI calculated?
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-useing highest of the brachial pressures, and higher of each PTA or DPA value.
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what is the high thigh pressure w/ the 4-cuff technique?
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-20mmHg higher than the brachial pressuer due to the narrow cuff width
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what is a normal difference w/ segmental pressures between segments?
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difference of 20mmHg
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TBI'
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-toe brachial index
-assess disease of small vessels of toes and foot. -relied upon when arteries are too calcified for ABI -toe brachial pressures are normally 60-80% of ankle pressure -a TBI <0.66 is abnormal |
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what are the benefits of segmental pressure testing?
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-provide physiologic information
-confirm vascular etiology -simple creening test |
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what are the limitions of segmental pressure testing?
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-cant' distinguish stenosis from occlusion
-cannot determine exact disease location -inaccurate w/ calcified arteries(w/ diabetics or end-stage renal disease) |
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how do ankle systolic pressures compare to arm pressures in patients w/ hemodynamically significant arterial disease?
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-ankle pressures are less than arm pressure
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what is consistant w/ an abnormal ABI value?
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<1 or .95
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what is the benefit of using the 4-cuff method? why is this not the case w/ the 3-cuff method?
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-useful in differentiating inflow disease from femoral artery disease
-if pressure is abnormal w/ the 3 cuff method, it is unable to differntiate btw inflow disease and femoral artery disease |
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what ABI is suspicous for calcified arteries?
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->1.5
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HOW is TBI calculated?
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-by dividing the brachial pressure into the Toe pressure
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Explain teh 2 modes of post exercise acquisition?
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1)obtain serial pressuer measurements for 10 minutes post exercise
2)record only one post excercise pressure from each ankle and highest arm pressure |
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what, following exercise testing confirms the presence of arterial occlusive disease?
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-significant decrease in ankle pressure following exercise
-this also indicates the severity of the disese |
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PORH
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post occlusive reactive hyperemia:
-sometimes substitueded for treadmill exercise -low thigh systolic pressure is kept on for 3 minutes -following release, the anke presure is recorded -with occlusive disease, there is a significant dicrease in ankle pressure when thigh cuff is released. |
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what is suggestive of subclavian artery stenosis?
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-a pressure gradient of 20 mmhg or greater btw brachial pressures suggests subclavian artery stenosis on the side of the lower pressure. If the rt brachial pressure is lower, the obstruction could be in the innominate artery
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What is more common; lt or right subclavian artery stenosis?
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Lt, and is the most common location of atherosclerotic disease in the upper extremeities
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what may happen in the presence of significant Lt subclavian stenosis/occlusion?
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-left vertebral artery flow may reverse direction to supply blood to the arm .
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explain how skin temperature affects vascular testing?
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-should be in a warm room to pervent vasoconstriction, which can adversly affect test results
-skin temp assessment is usedful in evaluation of raynaud's syndrome by doing pre and post cold immersion tesnting of the hand or foot. |
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Transcutaneous oximetry
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-aka TCOP2:
-measures oxygen ontent in the tissues which indicates perfusion -depends on balence btw O2 supply and O2 consumption of patient -measurement of PO2 at the surface of the skin are usually within 1-2% of the true value -useful in determinig wound healing potential and amputation level. |
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what may happen to the poptieal vein in a supine postion w/ the leg straight?
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-it may be extrinsicly compressed resulting in an abnormal doppler signal and venous flow
-if a patient is supine dring a venous doppler exam, there may be an absence of respiratory phacsicity in the venous flow signal |
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what is the appropriate patient and limb position for venous duplex imaging exam?
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-upper body elevated 15-30 degrees
-leg slightly bent at the knee and externally rotated |
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how should a patient be postitioned for a venous plesmography outflow study?
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-supine w/ legs elevated above the level of the heart
-this ensures max blood volume in leg -arms should be resting comfortably at the patient's side, or abducted to prevent compression of the axillary vein |
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when are tourniquets used?
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-in PPG venous reflux testing, they may be used to occlude the greater saphenous vein and lesser saphenous to help diffentiate superficial from deep vein incompitancy
-if abnormal venous reflux becomes normal after retesting w/ tourquinets, the incompetance is likely in the supericial venous system and perforators -venous outflow may be reduced w/ blood pressure cuff tourniquets placed on thigh |
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how ds limb volume change thoughout the cardiac cycle? how can this be measured?
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-increase in limb volume in systole and decrease in diastole
-assessed w/ plethysmography or PVR |
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explain venous outflow and tourniquets
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-venous outflow may be reduced w/ blood pressure cuff tourniquets placed on the thigh.
-w/ a supine patient, 50mmHg cuff will restrict venous outflow until the intraluminal pressure exceeds cuff pressure -at this point, flow resumes -tourniquet restriction, and rlease is the basis of measureing venous capacitance and outlflow. |
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MVO
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maximum venous outflow-the rate of outflow following release of vnous tourniquet
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arterial occlusion by cuffs
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-cuff inflation will stop arterial inflow under and distal to the cuff
-to be acurate, cuff bladder should be 20% wider than limb diameter at the cuff placement site -if the cuff is too small, limb pressure will be artificially high -this occurs in the upper thigh using a 12cm cuff -prolonged arterial occlusion from a cuff causes vasodialation in the distal vascular beds. This is the basis of post-occlusive reactive hyperemia testing in the lower arterial examination. |
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what is the basis of post-operative reactive hyperemia testing in the lower arterial examination
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-prolonged arterial occusion by the cuff causes a vasodialation in the distal vascular bed.
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compare the pulse of chronic arterial insufficiency to chronic venous insufficiency
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-arterial-decreased or absent pulse
-venous-normal(edema may make palpitation difficult) |
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compare edema in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-usually no edema, but mild if present
Venous-usually edema, and may be marked |
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compare temperature in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-cool
Venous-normal or warm |
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compare color in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-elevation pallor and depandant rubor
venous-normal(may be cyanotic w/ dependancy) |
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compare skin changes in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-thin shiny skin w/ loss of hair; thickened nails
Venous-brown pigmentation around the ankles; dermatitis may be evident |
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compare ulceration in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-involves toes when present; punched out appearance
Venous-involves the sides of ankles |
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compare gangrene in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-may develop in final stages
Venous-does not develop |
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compare pain in chronic arterial insufficiency to chronic venous insufficiency
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Arterial-may be severe
Venous-absent-or mild when present |
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with segmental limb testing, what are the pressures compared to?
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-contralateral limb presures
-adjacent segments -brachial pressure |
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when is a 20mmHg difference in pressure significant?
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when there is an abnormal ABI
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when there is high thigh cuff artifact, how does this change the proximal thigh pressure?
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due to the high thigh cuff artifact, a prox thigh pressure 20-40mhg higher than that of the arm is normal
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If the prox thigh pressure is <20mmhg above that of the arm, what does this suggest?
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-aortoilliac, CFA stenosis
-may be due to SFA occluasion w/ disease in the profunda -SFA stenosis alone does not cause prox thigh pressure to be abnormal |
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what does an abnormal gradiant btw below the knee cuff and the ankle cuff indicate?
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-ibioperneal(runoff) occlusive disease
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what effects segmental pressure testing?
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-thigh cuff artifact
-rigid arteries -tissue density |
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when should a BP not be taken on a patient?
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-if they have a graft or hemodyalysis
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how is ABI calculated?
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-bilateral akle pressures/the higher brachial pressure
-highest pressure used for ABI |
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if the ankle BP is >300mmHg, what does this indicate?
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-calcified arteries
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what is the exception for ABI normals?
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-if the brachial systolic pressure is <100mmHg, or >200mmHg, the ankle pressure may be 20% lower than brachial pressure
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what are the toe pressures usually like in comparasin to the akle pressure?
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60-70% of the ankle pressures
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what is the normal, abnormal, claudication, and rest pain ABI numbers for TBI's
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Normal-0.8-0.9
abnormal-<0.66 claudication-0.35-0.15 rest pain-0.11-0.1 |
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compare arterial and venous ulcers for the following
1) capillary refill 2) ankle-brachial index 3) dermatitis 4) pruritis |
Capillary refill-veous ulcers take less than 3 seconds while arterial ulcrs take more than 3 seconds
-ankle-brachial index: venous ulcers->0.9 arterial ulcers-<0.8 -dermatitis frequently occurs w/ venous ulers, but rarely with arterial -pruritis frequently occurs w/ venous, and rarely w/ arterial |
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explain the normal pressure index, and other information about the ankle pressure readings?
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normal=>1.0
ABI 0.6-0.9=mild to moderate disease <0.5=severe disease |
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explain the normal pressure index, and other information about the ABI's at the thigh?
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normal=>1.1
thigh pressure is usually 20-40mmHg higher than arm pressure |
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What is the normal toe index, and toe pressures?
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index=0.7-0.19
toe pressure=80-90% of brachial pressure -pressure<20mmHg=rest pain |
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explain arm index, and arm pressures
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forarm/arm index should be>0.9
-no more than 20mmHg difference between sides -forarm pressure should be>brachial pressure |
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explain finger indices, and pressures
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Normal finger/arm index is >0.95
-finger pressure should be>arm pressure -wrist/finger gradient should not exceed 30mmHg |
