Arterial (Quiz 3) Flashcards
Where are areas of potential compression in the chest?
over first rib between anterior and middle scalene muscles (scalene triangle), costoclavicular space bound by clavicle and first rib, pectoralis minor space (infrequently involved)
What is the thoracic outlet?
where the nerve and vessels leave the chest and go into the arm
Where does the axillary artery transition to the brachial artery?
at level of the inferolateral border of the tere major muscle
What arteries branch from the brachial artery? Why are they important?
deep brachial, radial, and ulnar recurrent arteries
important collaterals
What are anatomic varients of the upper extremity?
high take off of radial artery, accessory or duplicated brachial artery, and origin of ulnar artery in upper arm (less common)
What does upper extremity PAOD typically appear as?
positional extrensic compression (TOS) or cold-related vasospasm (Raynaud disease or phenomenon)
What are the causes of upper extremity PAOD?
mechanical obstruction (TOS), embolism, trauma, digital artery vasospasm (Raynaud disease), and digital artery occlusion
What diseases are related to cold sensitivity?
episodic digital artery vasospasm related to cold exposure or emotional stress, primary and secondary Raynaud disease
Describe the general difference between primary and secondary Raynaud disease.
primary is idiopathic vasospasm and secondary is associated with underlying condition such as scleroderma or trauma
Describe the Raynaud phenomenon.
first the fingers become white due to lack of flow; then fingers become blue as vessels dilate and finally are red as flow returns
What is the incidence of Raynaud sydnrome?
more common in young females of the asian popluation and also those in cool, damp climates
Which is more concerning, primary or secondary Raynaud syndrome?
secondary
List the symptoms for primary raynaud syndrome.
pain and color changes of fingers (white, blue, and red)
What is the result of pirmary and secondary Raynaud syndrome?
primary: rarely results in tissue damage
secondary: associated with tissue necrosis, patients tend to develop occlusive lesions
What is primary raynaud syndrome?
abnormal digital artery vasospasm
physiologic (stress)
What is secondary raynaud syndrome?
underlying disease process responsible for symptoms
What underlying diseases are associated with secondary raynaud syndrome?
autoimmune disorder (scleroderma), mixed connective tissue disease, lupus, rheumatoid arthritis, drug-induced vasospasm, cancer
What testing is done for raynaud syndrome?
duplex ultrasound (indirect) can help determine if digital occlusive disease is caused secondary from proximal source such as aneurysms, stenotic lesions, and fibromuscular disease of forearm arteries
What is fibromusclular disease? Who does if effect?
an abnormality of the intimal lining of the artery
beading of intima instead of smooth; creates structural stenosis
effects younger females
Even though duplex US is possible for digital arteries, what is more routinely used?
PPG waveforms
What is thoracic outlet syndrome? Who does it effect?
a disorder that occurs when certain blood vessels or nerves are compressed
more often effects people who build muscle (when muscles in the arm are built up, it narrows the thoracic outlet)
What are the symptoms of TOS?
numbness, aching, or tiredness when positional changes of the shoulder
“I always have symptoms when…” - positional symptoms
What are the results of TOS?
results in compression of the nerve (95%), vein (3-4%), and/or artery (1-2%) at the thoracic outlet
What is most commonly compressed with TOS?
the nerve
What is nervous TOS? What is the compression due to?
impingement of the neurovascular bundle at the thoracic outlet
cervical ribs, abnormal fibrous bands, hypertrophy of the scalene muscles
What is the treatment for nervous TOS?
remval of the 1st rib to open up the thoracic outlet
What may be used to confirm neurogenic TOS? What is the drawback?
duplex US
20% of normal individuals can demonstrate subclavian artery compression with provocative maneuvers
What is the incidence of arterial TOS? What may arterial TOS be due to?
in younger patients
may be due to large cervical ribs, clavicular abnormalities, after trauma
What is arterial TOS?
compression and damage to subclavian artery
What can repeated trauma of arterial TOS cause?
aneurysm, stenosis, ulceration or occlusion of subclavian artery
What can be used to document the abnormalities of arterial TOS?
duplex US
What is an aneurysm?
permanent localized dilation resulting in 50% increase in diameter of an artery compared to adjacent normal artery
In association to TOS, where do aneurysms usually occur?
subclavian artery
can also occur in the hand (hypothenar hammer syndrome)
Are subclavian aneurysms seen with ultrasound?
yes, but with difficulty due to overlying bone
How do subclavian aneurysms develop?
develop due to change in pressure due to stenosis
aneurysm elsewhere is associated with trauma
What is the etiology for aneurysms?
atherosclerosis and trauma
With atherosclerosis and trauma, what arteries are aneurysms associtated with?
more with axillary, brachial, raidal and ulnar arteries
not common lesions
present as pulsatile mass
What is hypothenar hammer syndrome?
arterial degeneration of ulnar artery as it passes deep to hook of hamate bone
What is associated with hypothenar hammer syndrome?
repeated use of palm of hand as a hammer
What does a sonographer look for (vascular) with a trauma patient in an arterial duplex sonogram?
examine injured area for intimal tears, dissections, or other abnormalites
What happens with an arterial dissection?
because of trauma or iatrogenic injury, a vessel layer (most commonly tunica intima) is ripped and some blood will get underneath that layer creating a false lumen. That false lumen will run out of room, so the blood will invade the other vessel wall and head the oposite direction. The false lumen will cause stenosis of the true lumen and will show an eleveated velocity and turbulent flow
What is arterial occlusive disease?
significant atherosclerotic disease in the upper extremity usually involves the proximal subclavian artery
Where does arterial occlusive disease occur most often?
left subclavian
often an extension of atherosclerotic involvement of the aortic arch
What are symptoms of arterial occlusive disease?
rarely produces symptoms in upper extremity but may result in subclavian steal syndrome
What is subclavian steal syndrome?
reversal of flow in ipsilateral vertebral artery
What is the incidence of Takayasu’s arteritis?
primarily effects asian females between 20-30
What is takayasu’s arteritis?
autoimmune disorder that affects the arteritis of the aortic arch and visceral abdomina aorta
soft tissue inflammation of soft tissue wall
What does takayasu’s arteritis result in ?
long segment occlusion or stenosis of affected arteries
Takayasu’s arteritis is associtated with…
acutely associated with fever, malaise, arthralgias and myalgias
lab values of elevated erythrocyte sedimentation rate and c-reactive protein
What is the treatment for takayasu’s arterities?
steroid and immunosuppressive medication
patients may need vascular reconstruction after acute phase
What is the incidence of giant cell arteritis?
primarily affects caucasion females over 40
Giant cell arteritis can involve…
ophthalmic, subclavian, axillary, and superficial temporal artery
US duplex findings in the acute phase of giant cell arteritis includes what?
evidence of flow restriction and thickened hypoechoic arterial wall
What is giant cell arteritis?
(temporal arteritis)
inflammation of blood vessels in and around the scalp
an autoimmine disorder
What is the treatment for giant cell arteritis?
anti-inflammatory and immunosuppressant medications
Describe thromboangiitis obliterans,
when toxins accumulate in the blood stream and end up in the digits because of the small vessels
Where is buerger disease occur?
primarily in the hands and feet
What is the incidence of thromboangiitis obliterans?
smokers (only) under 50??
Is ultrasound used to detect buerger disease? What is the treatment?
duplex US is used to rule out proximal occlusive lesions
most patients improve with cessation of smoking
With end stage renal disease, what may be seen?
ischemia and gangrene can be seen in patients with dialysis grafts or fistulas
What test is done in end stage renal disease?
duplex US to evaluate for steal phenomenon
With diagnostic testing, what is being differentiated?
large v. small vessel
vasospasm or obstruction
What percentage of upper extremity disease is small vessel obstruction?
95%
With upper extremity testing, what test is performed first?
indirect testing
because of digit arteries
What additional questions should be asked for patient history with upper extremity testing?
symptoms related to positional changes or cold sensitivity
With upper extremity segmental pressures, where are the cuffs placed? What arteries are used?
upper arm, forearm, and wrist
radial and ulnar arteries are used for wrist pressures
If PAOD is found in the upper extremities, what arteries is it most likely to occur in?
subclavian and proximal axillary arteries
Using continuous wave doppler, doppler waveforms are obtained from what arteries?
subclavian, axillary, brachial, radial, ulnar
What pressure discretion indicates the presence of subclavian artery stenosis?
> 15 mm Hg difference in brachial systolic pressures
>15 mmHg difference between adjacent segments indicates disease as well
Using Doppler to diagnose, what can waveforms be categorized as?
triphasic, biphasic bidirectional, biphasic unidirectional, monophasic moderate/severe, an monophasic/critical
How are digital evaluations done?
digital cuff is used, PPG used to obtain waveform and presure, digital brachial index (DBI) can be calculated
What is a normal DBI?
greater than or equal to 0.8
Digital pressures are important in patients with what?
dialysis fistulas or grafts (assessing steal)
With warm hands, what will the PPG waveform look like?
may be normal or peaked
What is the cold sensitivity examination technique?
PPG is secured to digit and wrist, hands may be covered with gloves; hands are then placed in ice water bath for 30-40 seconds; digital waveforms (or temperatures) are measured at 2,5,and 10 minutes postimmersion
When the cold sensitivity exam is done, what is the reaction with Raynaud syndrome?
really painful
abnormal, vasospasm and doesn’t come back as quickly
When should normal digital tracings or temperatures return to pre-immersion levels?
within 10 minutes
How is thoracic outlet commonly tested?
by using PPG to record digital waveforms and in various positions
What are the different positions used for TOS digital testing?
arms resting in lap; elbows to rear and arms upright, palsm front (military postion); arms elevated above head; arms abducted rearward; arms straight out to sides with head ahead, then left, then right (Adson maneuver); any other position that elicits symptoms
What does an abnormal digital TOS exam look like?
abnormal results are reduction or flatline of waveform with any position
any position that causes waveform to flatline should be held for at least 30 seconds to see if patient develops symptoms
What is the allen test?
used to determine digital perfusion prior to certain surgical procedures
hand perfusion can be assessed from the radial and ulnar arteries, combined and individually
How is the allen test performed?
PPG waveforms are obtained from either the middle or forefinger
radial and ulnar arteries are compressed sequentially to determine if pulses are maintained
What happens if the waveform remains present with compression?
flow into hand will not be interrupted should radial artery be harvested
With direct testing of the upper extremity, how do you position the patient?
supine, head elevated;
to evaluate axillary artery, arm should be externally rotated and positioned away from body (pledge position);
head may need to be rotated
What are the windows for insonation with the subclavian artery?
sternal notch, supraclavicular, or infraclavicular approaches
What does a normal upper extremity waveform look like?
triphasic, sharp systolic peak, brief period of diastolic flow reversal, and minimal continued forward flow in diastole
normal PSV from 80-120 cm/s in subclavian
40-60 cm/s in brachial, radial, and ulnar
What do abnormal findings of the upper extremity look like?
elevated PSV, poststenotic turbulence, dampened distal waveforms with loss of end-diastolic flow reversal, general guidelines suggest velocity ratio greater than or less than 2 is consistent with greater than 50% stenosis, waveform changes and brachial blood pressures can help determine stenosis significance
