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203 Cards in this Set
- Front
- Back
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what are the treatment goals for TOS?
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-decompress TO
-repair arterial damage -bypass stenosis or occlusions -reverse acute occlusions where possible |
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what conditions are associated w/ arterial occlusion?
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inflammatory conditions-eurger's disease, and takayasu
s syndrome -frostbite-chronic vasoconstriction |
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what is the classic clinical presentation of of buerger's disease?
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-black foot
-male(30-50) -smoker |
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primary raynaud's syndrome
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-benign
-affects young women -intermittent ishemia caused by prolonged digital basospasm -due to exposure to the cold, chemicals(nicotine), or occupational traume(vibration injury) to the hands |
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what are the risk factors for a pseudoaneurysm?
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-patients who have undergone procedures involving arterial cannulation
-trauma -iatrogenic or surgical trauma |
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what are the disease mechanisms for compartment syndrome
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-swelling within a confined compartment that compresses vasculature and nerves
-may cause tissue necrosis and embilis |
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arterial TOS-complications
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-permanent lesions and thormboembolic events
-limb thretening condition -due to congential bony anomoly -takes longer to develop than neurogenic and venous TOS(shows up later in life) |
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what are the goals for diagnosis of Popiteal entrapment?
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-determine course of popiteal artery
-asses patency -assess doppler waveforms at reast and then w/ plantar flexion -assess for dialation -popiteal aneurysm criteria=>1cm diameter |
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what are the signs and symptoms of a ruptured aneurysm?
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-unexplained syncope
-hypotension -hypovolemia -cardiovascular collapse -clinical shock -tachycardia -abd/back pain, pulsitile mass, and hypotension is the classic triad, and only exists in 1/3 of patients -most have normal and equal femoral pulses |
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arterial TOS
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-rare
-occurs secondary to compression of the subclavian artery -due to cervical ribs, first ribs, or old clavicle fractures -affected artery may show post stenostic dialation or aneurysm formation -usully present w/ thromboembolic symptoms |
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entrapement syndrome
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-compression of an artery btw 2 muscles
-popiteal and thoracic outlet syndrome are 2 types |
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what are the testing goals for reynaud's disease/phenomenon?
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-rule out underlying stenosis
-determine vasoreaction to cold -cold test -PPG |
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acute arterial occlusion
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-caused by embolus, thrombus, or trauma
-6 P's(pain, pallor, paresthesia, puselessness, paresthesia, and polar) |
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what should be measured w/ AAA's on ultrasound
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-extend of aneurysm
-if it is below or above renal arteries -extension of aneurysm |
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popiteal entrapment
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-trainsient compresion of the popiteal artery as it courses through the popiteal fossa
FACTORS OF COMPRESSION: -aberrant course of artery -scarring of surrounding structures -anomolous placement of structures |
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beurger's disease
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-inflammation of the perpheral vessels leading to occlusion and ishemia
-in small vessels are involved, there may e gangrene and loss of digits -the affected area is swollen, painful, and pulseless |
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peroneal artery
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-adjacent to border of fibula
-terminates as external calcaneal artery -supplies lateral leg and foot |
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what is the clinical presentation of buerger's disease?
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-cold extremity
-parestheis -skin color changes -rest pain -intermittant claudication -gangrene or ulceration -superficial thrombophlebitis |
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what are the causes for acute arterial occlusion?
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-atherosclerosis
-embolic from proximal site -surgical procedures -arterial cannulation |
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what are the diagnositic goals for TOS?
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-determine extent of arterial involvement
-check underlying stenosis of the limb -check for changes in arterial flow w/ postural changes |
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what are the signs and symptoms of chronic arteritis?
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-obliterative changes in the aorta
-fibrotic changes in the arterial wall -accelareated atherosclerosis -aneurysmal changes |
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what are the signs and symptoms of acute arteritis?
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-malaise
-fever -night sweats -weight loss -athralgias -fatigue -anemia -elevated ESR |
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vasospastic disorders
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-vasospasm of digital arteries induced by exposure to cold
-symptoms include pain, parethesia, and skin color changes -common cold sensitivity condition is raynaud's phenomenon |
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what are the complications and general symptoms of arteritis?
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complications: occlusion and embolization are common
symptoms: -low BP -pale cyanotic limb -bruits -paralysis or mscle wasting -extremeity size difference |
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what are the types of non-atherosclerotic lessions?
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-primary and secondary reynaud's syndrome
-coarctation of the AO -entrapment syndromes -arteritis |
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external iliac arteries
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-course along innre border of the psoas to the inguinal ligament where they become CFA`s
-two branches dorsally: inferior epigastric and deep iliac circumflex artery |
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what is another form of ulcer?
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-located over pressure pain
-surrounded by callous -associated by neuropathy |
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hypothenal hammer syndrome
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-damage to the ulnar artery from constant pounding of the heand on theat side
SYMPTOMS: -pain -numbness -tingling -weakness of grip -discoloration of fingers -ulcers -raynaud's phenomenon |
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what are the symptoms of dissection?
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-back/chest pain
-symptoms of emboli -often insidental |
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signs and symptoms of popiteal entrapment?
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-young athlets
-claudication symptoms -as fibrosis occurs due to comression, stenosis and eneurysms may occur -cramping of the calf and foot -blanching -numbness -unilateral symptoms -palpable pulses at rest but obliteration w/ flexion |
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what are the signs and symptoms of chronic occlusive disease?
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-claudication, ishemic rest pain, tissue loss
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neurogenic TOS
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-pain, parestheia, and weakness of the upper limb
-aggravated by overhead posture -symptoms caused by irritation of brachial plexu -most patients(90-95) have this type of TOS -usually 30-50 yrs, and females have it 4 times more often than males |
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blue toe syndrome
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-may occur w/ microemboli to the smallest vessels of the toes
CAUSES: -ulcerated and or atherosclerotic lessions -embolization -inflammatory process of arteritis -some angiographic procedures |
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acute stage of beurger's disease
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-swollen tense artery w/ edema
-lumen obstructed w/ fresh thrombus -critical limb ishemia - |
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what is another name for buerger's disease?
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thromboangitis obliterans:
-affects males more than females -prevelent in smoking population -reynaud's phenomenon occurs -cessation of smoking causes disease to go away. |
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what are the diseases associated w/ small artery injury?
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hypothenar hammar syndrome
vibration induced white finger |
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venous TOS
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-rare
-from thrombosis of subclavian or axillary vein secondary to compression -symptoms noticed w/ movement of the arm -lim may be edematous w/ distended superficial veins |
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what are the signs and symptoms of PSA?
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-excessive bleeding/swoolen extremity following arterial cannulation
-palpable, pulsitile mass at site |
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what are the symptoms of neurogenic TO?
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-women 30-59
-history of cerviothoraci trauma -certain activities aggrivate the symptoms(stretching plexus, hyperabduction) -pain along neck, lateral shoulder, anterior chest, or parascapular region -parestheia and numbness in distal extremity |
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what should be done when observing the distal leg for features of chronic arterial obstructive disease?
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-trophic changes(hair loss, shiny, dry, scaly skin)
-color changes -poorly healing ulcers -gangrene -blue to syndrome -palpate pulse, and assess skin temp. |
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what are the risk factors for accute arterial occlusion?
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-arterial cannulation
-atherosclerosis -coagulopathis -heart disease(if you have arrythmia, AV stenosis, ect, you can throw an emboli) |
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what are some inflammatory conditions associated w/ arterial occlusion?
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-berger's disease
-takayasu's syndrome |
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arteritis
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-inflammation of a n arterial wall
-most common is buerger's disease aka. thromboangitis obliterans |
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what are osseous anomolies associated w/ TO pathogenesis?
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-cervical rib-displaces brackial plexis cranially
-long transverse process of the C7 vertebra-causes direct compression of the plexus -first rib-borders three anatopic spaces which brachial plexis pass |
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what are soft tissue anomolies that have to do w/ TO pathogenesis?
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-anomolous placement of scalene muscles
-scalenus minimus muscle -congenital myofascial bands and ligaments -brachial plexus may be anaomolous |
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if there is a totally occluded Lt ICA,what are some possible collateral flow routes
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-collateral flow through other side of circle of willis
-colateral route through poterior cerebral circulataion |
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why does collateral circulation develop?
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because of a change in the PG btw vessels, causes by obstruction or stenosis
-distal to a significant stenosis, there is pressure drop -if the pressure drops enough to attract flow, blood vessels may abandom their normal flow routes to take advantage of the new, lower presssure route ie. subclavian steel |
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external to internal carotid collaterals
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-second most NB anastamoses
-aka preswillisian anastamosis -the best known one is btw the ECA and ICA through the orbital and opthalmic arteries |
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when do collaterals form?
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-depends on the age of the individual and the time of occlusion
OLDER PATIENTS: -collateral pathways are more likely to be hypoplastic -involved with atherosclerotic process ---collateral flow has a better chance of developing in persons with slowly evolving atheroscerotic processes. |
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name and explain the 3 categories for intracranial collateral circulation
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1. larg inter-arterial connections: other side of the circle of willis
2. intracranial-extracranail anastamoses(preswillisian anastamosis) 3. small inter-arterial communications(rete mirabelle) |
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collateral possibilities in the brain?
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-Rete mirabelle(wonderful net)
-occipital branch of the ECA communicating with atlantic branch of the vertebral artery -deep cervical branch of subclavian artery communicating with the proximal branch of the vertebral artery -descending and ascending crvical branches of the subclavian artery connecting w/ branches of the lower vertebral arteries, the atlantic branch of the upper vertebral artery, and the occipital branch of the ICA -the ECA communicating across the midline |
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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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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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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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what arteries supply collateral circulation?
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-lumbar
-MCA -SMA |
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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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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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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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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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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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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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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 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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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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MVO
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maximum venous outflow-the rate of outflow following release of vnous tourniquet
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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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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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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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plesmograph
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pressuer transducer connected to a strip recorder
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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 |
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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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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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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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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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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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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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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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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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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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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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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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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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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 effects segmental pressure testing?
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-thigh cuff artifact
-rigid arteries -tissue density |
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explain mild stenosis, it's percentage, waveform, spectral broadening, and PSV
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MILD:
-1-19% steosis -triphasic waveform -some spectral broadening -PSV is less than double that of closest prox normal segment |
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explain moderate stenosis, it's percentage, waveform, spectral broadening, and PSV
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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 |
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explain severe stenosis, it's percentage, waveform, spectral broadening, and PSV
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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 |
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explain near occlusion , it's percentage, waveform, spectral broadening, and PSV
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NEAR OCCLUSION:
->80% -flow dininishes and waveform becomes damped -reverse flow component is absent TOTAL OCCLUSION: |
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explain occlusion, it's percentage, waveform, spectral broadening, and PSV
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-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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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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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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Virchow's triad:
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Virchow's triad:
-endothelial damage -vneous stasis -ypercoagulability |
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phlegmasia curula dolens
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bluish discoloration
-results from severely reduced venous outflow from iliofemoral thrombosis, which decreases arterial flow, a limb-threteing conditionv |
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explain the effect of congestive heart failure and shallow breathing on flow in the veins?
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-Congestive heart failure-cuases veins to distend to to inability to empty all blood into atria
-shallow breathing-don't fully distend their diaphragm, so the effect of respiration is not evident(venous flow will be more continuous) |
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Explain the capabilites and limitations of photo outflow plesthsmography
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CAPABILITIES:
-helps evaluate venous insufficiency LIMITATIONS: -inability to determine the site of involvement -cannot differentiate btw superficial and deep -collaterals affect results -venous stasis ulcere in malleolar area may limit th exam |
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predisposing risk factors for peripheral venous disease
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-age
-cancer-malignancy -pregnancy -hormonal changes -recent surgery -immobility -congenital thrombophilia -previous DVT |
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lesser saphenous vein(LSV)
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-begins at dorsum of foot
-courses behind lateral malleolus to popiteal space and terminates at popiteal vein. -contains 3-9 valves -in up to 30% of individuals, it termiates at the GSV, Giacomini vain, or femoral vein instead of popiteal. |
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how is treatment for stasis ulceration done?
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-keep area clean and medicated
-unna boot, which provides venous compression -skin grafts |
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why is it bad for the sonographer when a patient cries, or falls asleep during an exam?
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-Crying=results in hyperventellation, and a decrease in CO2
-falling asleep=during the TCD=hypoventilattion=increase in Co2 |
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what are some tests used to differentiate reynaud's from primary and secondary?
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warm testing
cold testing skin thermometry |
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Explain the interpretation of digital assessment?
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NORMAL:
-normal systolic pressures -80% of normal ipsilateralo brachial pressures -finger-brachial index=0.8-on ipsilateral side -waveforms should be sharp upstroke and dicrotic notch OBSTRUCTIVE DISEASE: -funger pressure measurements<70mmHg -brachial/finger differences>35mmHg FINGERTIP ISHCEMIA: -wrist to digit difference=30mmHg -finger to finger difference=15mmHG |
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lymphedema
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-obstruction of the lymph system
-cuases swelling and pain -may occur in neoplastic, inflammatory conditions, or surgical interuption |
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what are the limitations of CW doppler with peripheral venous testing?
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-subjective technique
-non-obstructive thrombus may not be detected -unable to reliable detecte isolated calf vein thrombi -w/ good collateralization, normal flow may be detected distal to a thrombosed vessel |
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How is sympathetic nerve activity interpreted?
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NORMAL PATIENT(intact sympathetic nervous system):
-inspiration-rapid rise in digital volume -respiration suspended-plethsymographic tracing becomes level -expiration-rapid decrease in volume PATIENT FOLLOWING SYMATHECTOMY(nerve removal): -inspiration-initail rise in digital volume -expiration-no change in pulse volume and total digit volume |
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explain venous insufficiency during contraction, and relaxation
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CONTRACTION:
-incompetant valves allow blood tomove from deep to superficial system during muscle contraction RELAXATION: -incompetent valves in the deep, superfocoa;. amd perforating veins allow blood to flow in a retrograde direction |
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Explain arterial carbon dioxide partial pressures
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-decreased CO2=decreased cerebral blood flow, and decreased intracranial arterial velocities
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explain the technique for cold testing?
|
-record pre-submersion PVR's or PPG's
-place symptomatic hand in a plastic bag without removing the PPG, or PVR cuffs -submerge hand in basin of ice water for 1-2 minutes or as patient tolerates -obtain post sumbersion tracings -obtain tracings at 2-3 minute intervals -if tracings return to baseline within 5 minutes, discontinue testing -if tracings remain low, continue recording at 2 minute intervals |
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what has a similar appearance to DVT?
|
baker's cyst and joint effusion
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support hose
|
-wear support hose or elastic stokings
-elevate legs -limit long periods of inactivity or bed rest -use intermittent pneumatic calf compression during and after surgery |
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Venous insufficiency: what is it, and what does it permit?
|
it is:
-inadequate drainage of a venous blood from a part -results in edema or dermatosis -most often seen in lower extremities(due to hyderostatic pressure) PERMITS: -reversal of flow in veins -venous hypertension in distal segments |
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functional reserve tesing
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can check reactivity of the cerebral vessels with a CO2 challenge test
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when is functional reserve testing done?
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-done in patients who have critically reduced cerebral blood flow due to complex multivessel atheroscerotic disease, an unfavorable configuration of the circle of willis or both
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what are the capabilites and limitations of air outflow plesthympgraphy?
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CAPABILITIES: can detect obstructive thrombus in the liliac, femoral, and popiteal veins
LIMITATIONS: -unable to detect calf vein thrombus -cannot detect small thrombus -false positives may occur with: CHF, tricuspid insufficiency, severe pulmonary problems, severe arterial insufficiency, extrinsic obstructions such as a tumor. |
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phlegmasia alba dolens
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-whiteness of lower extremity caused by arterial spasms due to extensive, acute iliofemoral thrombosis, a limb-thrteming condition
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Greater saphenous vein
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-begins at dorsum of foot
-corses behind tibia, and terminates at CFV -contains 2-6 valves -recieves blood from subdural tributaries -many variations occur here -longest vain in the body(may be used for arterial bypass grafts) |
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skin thermometry
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-not done very often because it's hard to control
-when 2 adjacent areas exhibit noticable temperature differentces under identical conditions, this is suspicous for vascular disease or spasm |
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what are the signs and symptms of acute and chronic DVTq
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ACUTE:
-redness -edema -warm to touch -pain CHONIC: -discoloration -hyperpigmentation: brown discoloration in lower leg to ankel(gaiter zone) |
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what is the technique for TOS?
|
-attach PPG to patient's palmar surface or first finger tip
-record baseline PPG pulse waves -have patient perform differnt maneuver and record pulse waves |
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what is the difference btw cellulitis, and an abscess, how are they similar?
|
cellulitis=diffuse
Abscess=focal Both are bacterial infections and can appear similar to DVT: -pain -swelling -skin erythema |
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calf muscle veins
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-venous sinusoids collect blood from soleal and gastrocnemius muscles
-empty when calf muscle pump is activated -soleal veins-drain into peroneal or posterior tibial veins. -gastrocnemius veins drain into popiteal vein. |
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explain the method, interpretation, and limitations of venography/
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METHOD:
=contrast agent inject into foot to demonstrate venous system -radiographs taken of entire leg to demonstrate venous system and any disease that may be present LIMITATIONS: -painful for patient -chemical phlebitis may occur due to contrast agent -differntiation btw acute and chromic is difficult |
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acute venous thrombosis
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-usually begins at soleal sinuses and propegates up the leg; or it forms at the site of venous intimal injury
-higher risk as the disease moves proximally -thrombus from trauma may occur at any level - |
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why might extrinsic compression result in thrombosis formation of the common iliacs?
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because the left CIA crosses under the Rt CIA.
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what does functional reserve testing measure, and identify?
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measures-response of the cerebral circulation supplied by the MCA to the inhalation of 6% CO2 for 3 minutes
-identifies-patients who have or are at risk for low flow ischemia and infarction |
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what types of operations are palmar arch patencies testing for?
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-for radial artery harvest(CABG)
-or hemodialysis access placement |
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how will recanalized thrombus appear?
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-bright fibrous webs within the vein
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soft tissue tumors
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-liposarcoma(most common soft tissue tumor)
-well circumscribed and encapsulated -often very large |
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what is the sonographic appearance of acute venous thrombus?
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-vein dialtated
-may be hypoechoic -may be partially attached and floating -not compressible with transducer pressure |
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How can congestive heart failure cause the veins to appear as arteries?
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-causes increased peripheral edema
-increased resistance in venous return which causes venous doppler signals to be very pulsatile and may appear similar to the adjacent artery. |
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What are the causes of venous insufficiency?
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COMMON:
-right sided heart failure -DVT -extrinsitc compression OTHER: -lyphatic system problems -reduced mobility/paralysis |
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Explain how the superficial veins of the upper extremity run?
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-superficial digital veins drain blood from tissues into deep veins
-superficial digital veins of the hand unite near the wrist to form cephalic and basilar -cephalic courses on the radial side, and cephalic unites w/ axillary and empties into the subclavian -basilic courses on the ulnar side, and unites with the brachial vein to become the axillary vein. |
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what is the patient postion, and technique for photo outflow plethsmography?
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POSITION: seated w/ legs dangling
TECHNIQUE: -PPG transducers appled to skin near medial malleolus -dorsiflexion and plantar-flexion of the feet performed 5 times to provide calf muscle pumping -leg is then completely relaxed |
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what does the valsalva maneuver indicate with the venous system?
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-results in abrupt cessation of blood flow in LG and Medium arteries
-cessation indicates patency from the point of doppler examination to the thorax- -abnormal reponse occurs only with substantial venous obstruction |
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what are the ultrasound characteristics of baker's cysts?
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-medial
-crecent in trx -upper end at knee joint -anechoic or low level echos -if they are ruptured, they cannot be confirmed by U/S |
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what are the capabilities of CW doppler w/ peripheral venous testing?
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-can detect obstructive thrombus in the iliac, femoral, and popiteal veins.
-can detect valvular insufficiency in both deep and superficial systems |
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what are the techniques for sympathic nerve activities?
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-attach PPG sensor(PPG or SPG) to digit
-set recoding device to DC mode-timing slow blood return -have patient inhale deeply, then suspend respiration -have patient exhale rapidly |
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how is air outflow plesthymography interpreted>?
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CAPACITANCE:
-volume of congested blood in teh calf after occlusion -measured from baseline, to max volume before deflation OUTFLOW: -volume of blood that flows out of the leg in the first 3 seconds after occlusion GRAFH INTERPRETATION: -capacitance and ouflow plotted on graph -if results fall below discriminent line, test is considered normal -if abnormal, repeat test 3-5 times to rule out false positive |
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digit testing(PPG)
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-use small cuff(1.5 cm)
-interpretation: change in pressure >20mmHg between brachial pressures indicates atherosclerotic disease |
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what are the immediate, and long term results of venous insufficiency?
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IMMEDIATE:
-soft tissue edema LONG TERM: -skin thickening -hyperpigmentation -skin ulceration |
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COPD
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chronic obstructive pulmonary disease
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portal system
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-consists of return blood from viscera to liver; forbed by SMV and spleniv vein.
-drains blood from intestines, spleen, stomach, gallbladder, and pancreasc |
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muscle and tendon tears
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-injury to muscle tissues which may resemble a thrombosed vein
-to rule out venous thrombosis, follow structure to determine where it leads |
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inflammatory response with cellulitis and abscess
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-hyperdynamic vascular response to inflammatory conditions
-prominent arterial and venous flow may be seen within the tissue |
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hypercoagulability
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thrombophillia-protein c and protein s deficiency
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Explain the patient position and techique for air outflow plethsymography
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PATIENT POSITIONING:
-supine w/ head flat and calf above heart to facilitate drainage -knee bent -leg externally rotated TECHNIQUE: -monitoring transducers are placed on the calf to detect volume changes as the cuff is inflated and deflated -occluding cuff placed above the knee and inflated above venous pressures, but below arterial(45mmHg) for 2 minutes -cuff is rapidly deflated and three second ouflow is measured |
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Surgery for the peripheral venous sytstem
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for chronic venous insufficiency-ligation of incopentant perforating veins
-vericose veins: -stripping or local excision of varicosities -sclerotherapy for venous close of GSV, LSV and small varicosities |
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explain the skin thermometry interpretation
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Normal patient:
-digital temperature returns to normal within 15 minutes -recovery half time<8 minutes ABNORMAL PATIENT: -patients who require >20 minutes to return to normal temperature -suspect raynaud's syndrome |
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what test is used for arterial TOS?
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-plesmography
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baker's cysts
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-dialation of the bursa posterior to the knee joint
-commonly associated with rhumatoid arthritis -appear to dissect the fascia planes and track into the calf -may spontaneously rupture -btw gastrochnemius muscle and semimembranous bands |
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what are the treatments options for peripheral venous treatment?
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-anticoagulation for DVT
-thrombolytic therapy -vena cava filter -support hose -surgery |
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what are the symptoms of venous insufficiency?
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-recurrent swelling
-varicose veins -venous claudication(releif by walking) -stasis dermatitis/hyperpigmentation -induration -ulceration |
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explain the method for testing for PPG
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-warm room
-patient sitting on edge of stretcher -PPG trx applied cephalad to medial malleolus w/ double sided tape -allow system to equalibriate(steady baseline) -strip chart speed=5mm/sec -have patient plantarflex, and dorsiflex 5 times in 5 seconds -observe PPG during exercise and recovery period -stop test when PPG tracing achieves pre-exercise baseline level, reaches stable plateau, or 60 seconds elapses. -measure recovery time |
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explain the normal results of tourniquet test?
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-PPG indicates good venous emptying
-recovory time exceeds 20 seconds |
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what are the 2 ways to meaure resistance with IPG?
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-two wire method cannot be calibrated and is rarely used
-4 wire method measures the decrease in the voltage btw 2 points across a wire(more reliable and accurate) |
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what are some false positives w/ IPG?
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-post thrombotic syndrome w/ large collaterals
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explain the technique for SPG/IPG venous test?
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-pneumatic cuff inflated to 50mmHg
-results in increase in calf volume -allow rise to continue for 2minutes -Rapidly deflate cuff -resulting decrease in calf volume recorded until volume returns to pretesting levels |
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collecting cuff
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pneumatic cuff placed around patients thigh
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What are the advantages and disadvantages of contrast venography?
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ADVANTAGES:
-accurate diagnosis of DVT -useful when other modalities fail -identified location, extend and degree of attachment of blood clots DISADVANTAGES: -expensive -invasive(risk infection) -painful -risk of allergic reaction -may cause phlebitis or DVT -may not detect thrombus in duplicated systems |
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Light reflective rheography
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-refinement of PPG
-added compartment of a thermistor which measures skin temperature -relies on the same principle where increased temperature=increased blood flow, and increased volume -produces the same type of results as PPG PITFALLS: -not specific -cannot reliably detect obstruction |
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contrast venography
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-gold standard study
-catheter inserted into a peripheral vein -contrast injected -radiologies observes movement of solution though veins w/ a floroscope -x-rays taken simultaneously -any filling defect indicates displacement of contrast material vy thrombus |
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Name and explain the theraputic surgical interventions?
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1)Venal caval interuptio:
-greenfiled or bird's nest filter -may be placed in the IVC, FV, or JV -Prevents emboli from moving to the lungs 2)Iliofemoral venous thrombectomy 3)ligation of superficial veins 3)varicose vein stripping or sclerotherapy |
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technique for air plethsmography
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--inflate chamber to 6mmHg
-ask patient to stand w/ weight on opposite extremity -the change in volume from supine to erect results from venous filling -have patient stand on both legs and do 10 heel raises -EF and residual volume may be measured w/ this method |
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explain the technique for SGP
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-silicon tube filled w/ mercury is wrapped around the calf w/ copper electrodes at both ends of the guage
-voltage applied across guage -calibration done at this point -cuff applied around the thigh, and inflated to 50mmHg -when the leg becomes distendeed w/ blood and the corrisponding circuference of the leg changes, voltage also changes |
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air plethysmography(APG)
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-used to assess the presence and severity of venous reflux
-a 14 inch long, 5L capacity polyvynil chloroid air chamber surrounds patients leg from knee to ankle -a bag is placed btw patients leg and chamber for calibration -patient lies supine w/ legs elevated 45 degrees -cuff is connected to a pressure transducer, an amplifier and a recorder |
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venous outflow plethsmography
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-combines 2 tests into 1 procedure; maximum venous outflow(MVO), and venous volume(capacitance)measurements
-allows determination of whether deep vein thrombosis is present at or aboove the knee |
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explain the meaning of incmetant venous valves, exercise testing and PPG
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-w/ excercise, blood should be pushed out of the calf by the calf muscle pump causing a decreased volume of the limb
-if the valves are working as they should, the refill time should be slow(>20sec) -a shorter refill time indicates valvular incopetence/ |
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DC coupling?
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aka direct current
-electrical voltage that is either positive or negative -current flow in only on direction -useful in evaluating very slow flow states |
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what are the capabilities of impedence plethsmography/
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-detect thrombi in iliac, femoral, and popiteal veins
-highly sensitive and easily affected by other factors -measures volume changes -not sensitive to calf vein thrombus |
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explain how IPG is interpreted?
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-if venous outflow is empeded, electrons do not move as freely(blood is the conductor, and flow is impared)
-as blood vlolume increases, resistance increases -results in changes in electrical impedance -a strip chart can measure a max venous capacitance as a peak in tracing -outflow is venous emptying after deflation -3 sec is normal outflow time; longer time indicates obstruction upstream |
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Explain PPG w/ incopetant venous valves( 2 ways)
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1. Calf volume is not reduced to to incompetant calf-veno motor pump
-PPG tracing oscillates up and down, but there is now lowering of the baseline 2. PPG trace lowers on a strip chart indicateing a decrease in volume, but tracing rapidly retruns to pre-exercise level. -indicates a return of valve volume via incopetent venous channels |
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explain PPG during calf muscle contraction and relaxation?
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-blood is normally pumped toward the heart
-venous blood volume in calf is reduced -decrease in blood content relects reduced calf venous PPG baseline tracing will course downward w/ each contraction -exercise stopped, blood volume slowly retturns via arterial capillary network -PPG tracing slowly ascends on the strip chart |
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what are some diagnostic tests for PE and DVT?
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-lung perfusion-VQ scan(nuc med)
-spiral CT angio -lung/leg MRI -pulmonary angio(gold standard for PE) -isotope venography -contrast venography(gold standard for DVT) |
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explain the IPG test?
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-current conducted through the electrodes appled to the calf
-measures volume changes caused by changes in blood volume -changes in resistance are major causes for changes in impedance |
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varicose vein treatment
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-sclerotherapy
-laser treatmetns -stripping or ligation |
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explain venous strain guage plesthmographY?
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-may detect venous obstruction in lg veins above the knee
-extremely sensitive test -quantifies altered calf volume |
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Spiral CT angiography
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-still investigationsl
-useful when evaluating central vessel involvement but not involvement of sugsegmental arteries -lung/leg MRI |
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SPG vs. IPG
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IPG=relection of limb changes in blood volume in the limb
SPG=uses changes on a strain on a mercury filled tube to determine electrical resistance(changes in limb circumference) |
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how may venous filling index be obtained?
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-by taking 90% of the venous volume and dividing it by the time taken to achieve 90% filling.
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how is ejection fraction for air plethsmography calculated?
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-by taking the expelled volume after doing 10 heel raises and dividing it by the total venous volume x 100.
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explain how APG is interpereted?
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-venous filling 100-350ml is seen where there is vascualr insufficinecy
-venous filling index obtained -filling index of 2ml/sec or less=normal -filling index of 7ml/sec=severe skin changes, chronic edema and ulceration |
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What are the normal venous refill times for PPG, SPG, and IPG?
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PPG->25 seconds
SPG->12 seconds IPG>11sec |
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For which transcranial arteries, is the flow going away from the transducer? toward?bidirection
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AWAY:(STABD VP)
-vertebral -P2 -suptraclinoid -terminal ICA -distal cervical carotid artery -ACA -basilar TOWARD:(POP M1) -MCA -P1 -parasellar -opthalmic BIDIRECTIONAL: -genu -ACA-MCA biffercation |
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which arteries are viewed by the transforaminal view?
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aka occipital view
-vertebral -basilar |
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which arteries are viewed by the transtemporal view?
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-MCA
-PCA -ACA-MCA biff -terminal ICA -ACA |
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which arteries are viewed by the transorbital view?
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-carotid siphon
-opthalmic |
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how is the opthalmic artery identified with TCD
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-window-transorbital
-depth-40-60mm -flow direction-toward the transducer -mean velocity-21+-5cm per second |
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what is one of the most important intracranial collateral patheay in the presence of significant ICA disease?
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cross-fill via the aterior communicating artery
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how is the MCA identified?
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-window-transtemporal
-depth-30-60mm -flow direction-toward the transducer -spatial relationship-anterior -mean velocity-55+-12cm per second |
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how is the bifercation btw the ACA and MCA identified with TCD
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-window-transtemporal
-depth-55-65mm -flow direction-bidirectional -spatial relationship-anterior and posterior -mean velocity-flow velocity is not assigned to bifercations flow; this is a landmark areaa to locate surrounding vessels |
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TCDI
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-transcranial color doppler imaging:
-uses color system q/ 1.9-2.2 frequency transducer -vessel identification aided by color -uses larger footprint than TCD -skull penetration is not as good as TCD -not used bilaterally or w/ halo |
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what do abnormal doppler waveforms look like with TCD?
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-increased frequencies or velocities are seen in: stenosis, vasospasms, arteriovenous malformations.
-decreased pulsitility seen in: significant stenosis, and occlusion -retrograde flow in a cerebral vessel indicates collateral or compensory flow for disease |
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how is the basilar artery identified with TCD
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-window-transforaminal(suboccipital)
-depth-80-120mm -flow direction-away from the transducer -mean velocity-41+-10cm per second |
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how is the terminal ICA detected with TCD testing
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-window-transtemporal
-depth-55-65mm -flow direction-away from transducer -spatial relationship-inferior to the MCA-ACA bif -mean velocity-39+-9 cm per second |
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how are intracranial vessels identified w/ TCD?
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rely on:
-depth -velocity -flow patterns -direction from spectral doppler |
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what are the clinical applications of TCD testing?
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(DAMPED SPIT MMMM)
-Diagnosis of intracranial vascular disease -assessment of intracranial collateral pathways -monitoring vasospasm in hemorrage -detection of cerebral emboli -Screening of children w/ sickel cell anemia -detection of feeders of arteriovenous malformations -intraoperative monitoring -monitorng evolution of cerebral circulatory arrest -monitroing anticoagulation or thrombolytic therapy -monitoring during interventions -monitoring after head trauma |
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how is the vertebral artery identified with TCD
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-window-transforaminal(suboccipital)
-depth-55-80mm -flow direction-away from the transducer -mean velocity-38+-10cm per second |
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how is the carotid siphon identified with TCD
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-window-transorbital
-depth-65-70mm -flow direction: sipralinoid-away genu-bidirectional parasellar-toward |
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what is seen w/ the submandibular approach?
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-retromandibular distal cervical ICA
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how is the PCA identified with TCD testing
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-window-transtemporal
-depth-60-70mm -flow direction-P1-toward the transducer P2-towards, away from transducer -spatial relationship-posterior and inferior to MCA-ACA bif -mean velocity-39+-10cm per second |
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`limitations of TCD
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-vessel angle is important but difficult to obtain
-anomalous intracranial vascular anatomy -recent eye surgery may make transorbital approach unnatainable -inability to penetrate the temperal bone adequately -aperator error w/ defining vessels |
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What conditions can TCD and TCDI detect?
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-stenosis
-vasospasm -AVM -suspected brain death -collateral flow |
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how is the ACA identified with TCD
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-window-transtemporal
-depth-60-80mm -flow direction-away from transducer -spatial relationship-anterior -mean velocity-50+-11cm per second |
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how is the distal cervical carotid artery identified with TCD
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-window-submandibular
-depth-45-70mm(usually 50) -flow direction-away from the transducer -mean velocity-30-34+-9 cm per second |
