Arterial UE

Question 1

Subclavian a becomes axillary a at

Answer 1

1st rib

Question 2

4 branches of subclavian

Answer 2

• Vertebral -1st
• Thyrocervical-
• Internal thoracic (internal mammary)
• Costocervical a.

Question 3

Brachial a bifurcates into radial and ulnar a at

Answer 3

Antecubital fossa

Question 4

Radial a travels lateral arm. And terminates into

Gives off branch in hand to form

Answer 4

Deep palmar arch.

Superficial palmar arch.

Radial artery joins deep palmar branch of ulnar a and terminates at deep palmar arch.

Question 5

Ulnar artery travels medically and terminates at

Gives off deep palmar branch.

Answer 5

Superficial palmar arch.

Question 6

Predominate source of blood to hand

Answer 6

Ulnar artery

Question 7

Avoid venous flow via

Answer 7

Valsalva maneuver. Light prox compression.

Question 8

Subclavian a waveform best obtained by _________ approach

Answer 8

Infraclavicular

Question 9

Axillary a vest obtained at

Answer 9

Inferior junction if arm and torso (axillary region or armpit)

Question 10

Brachial a runs down upper arm at ______ aspect of upper arm or antecubital fossa

Answer 10

Medial

Question 11

Radial artery

Ulnar artery

Answer 11

Thumb side of wrist. Use light pressure.

Pinky side

Question 12

Waveforms

Answer 12

Tri and Bi are normal.

Mono blunted round wave can indicate proximal stenosis or occlusion.
BP >20 mmhg

Question 13

Plethysmography

Answer 13

Cuff placed in arm and forearm.

Vol displacement in cuff during cardiac chcke.
Amount of air displaced with each beat.

Avoid movement

40-65mmhg

Question 14

Segmental pressure

Answer 14

Upper arm and forearm

Cuff should be 20% > than limb width.

If cuff too small may falsely elevate BP.
If cuff too big may falsely decrease BP.

If too tight, may decrease BP
If too loose, may inc BP

Evaluate brachial, rad and ulnar

Inflate 20mmhg over artery occlusion (no longer hear pulse)
Maintain Doppler probe position.
Release pressure at 4-5mmhg
Record pressure when hear pulse return.

Question 15

Pressure of >|= 15-20mmhg difference in bilateral brachial suggests

Answer 15

> 50% stenosis in subclavian, axillary, or brachial.

Question 16

Upper arm and forearm should not have a difference of

Answer 16

> 20mmHg

Question 17

Radial and ulnar pressures should be within ____mmHg of each other

Answer 17

10

Question 18

Photoplethysmography PPG

Answer 18

Light absorption. Used diodoid.
Evaluates fingers

Patient with cold hands can show dampened waveforms

Question 19

Tardus parvus all the way down right arm =

Answer 19

Innominate or brachiocephalic stenosis.

Question 20

Thoracic Outlet Syndrome TOS

Answer 20

Subclavian vessels and or brachial plexus are bound by clavicle, first rib, and scalene muscles.

Symptoms vary with limb position. Neurological

Cold
Pain
Aching shoulder
Extremity numbness

Pain originates from nerve compression.

Detect via: arterial Doppler, PVR and PPG. Monitor patient in TOS positions after baseline arterial Doppler in resting position. Especially the symptomatic position.

Patient with cold hands can have dampen waveforms in PPG

Dampened PPG waveform with position change.

Question 21

Raynaud disease (Primary raynauds)

Answer 21

Caused by digital arterial spasms in response to cold or stress.

Intermittent pallor->cyanosis->rubor

More common in young women

Usually bilateral.
Benign.
Patient presents with long term hx of symptoms without progression and without underlying cause.

Construction of vessels dec blood supply to fingers causing them to turn pale.

Fingers become white due to lack of blood flow, then blue as vessels dilate to keep blood in tissues, then finally red as blood flow returns.

Testing: baseline PPG.
Cold challenge: hands emerged in ice water 3-5mins. PPG waveforms obtained.

If pre emergent PPG levels come back within 10 mins = normal.
After 10 mins and PPG still flatline= abnormal

Question 22

Raynaud’s Phenomenon (secondary raynauds)

Answer 22

Cold sensitivity with a fixed arterial obstruction

PPG low amplitude and rounded.

More serious than Raynaud’s disease. Can lead to ulcer and gangrene.

Question 23

Palmar arch patency

Answer 23

Radial artery is assessed when it’s needed for coronary artery bypass or hemodialysis. To harvest radial artery.

Cannot be harvest if not patent or if palmar arch is incomplete. Because radial artery may be the only one supplying the hand.

Incomplete palmar arch:
Mixed dominance
Ulnar dominance

Question 24

Standard Allen test (palmar arch patency) May be unreliable

Answer 24

Compress radial artery
Clench fist
Release

If it stays white, you have an incomplete arch. Radial artery dependent.

If color returns, ulnar artery is feeding hand. It’s either complete arch or ulnar dominant arch.

Repeat with ulnar compression.

Question 25

Modified Allen test

Answer 25

Palmar arch patency test with PPG

PPG on index finger with radial artery compression. If perfusion continues = normal. Then compress ulnar artery. Perfusion should continue. Note which vessel compressing during exam.

If with radial compression, blood flow doesn’t return = incomplete and radial dominant. Harvesting radial artery would be contra indicated.

Question 26

If there’s a complete arch, even with radial artery stenosis, blood flow would still return because ulnar artery takes over.

Answer 26

True

Question 27

Radial artery harvest contraindications

Answer 27

Ischemic digits
Digit vasospastic disorder
Atherosclerotic occlusive disease in arms
Sclerotic or small radial artery.

Question 28

Vasculitis

Answer 28

Inflammation of blood vessels causing a thickened weakened scarred and narrow wall

• Giant Cell Arteritis
• Polyarteritis Nodosa
• Takayasu’s Arteritis
• Kawasaki (children)- coronary artery involvement
• Buerger’s disease

Question 29

Giant cell Arteritis aka Temporal Arteritis

Answer 29

Inflammatory process of the arterial wall affecting medium and large arteries

Usually >50 years with new onset headache and accelerated erythrocytes sedimentation rate. (Blood test that reveals inflammatory activity in body)

Can often affect branches of carotid. Especially temporal artery. Or other medium and large size arteries of the head and neck such as subclavian.

• visual disturbances
• headache
• neck/jaw pain
• scalp tenderness

Question 30

Polyarteritis Nodosa

Answer 30

Systemic vasculitis characterized by necrotizing inflammatory lesions that effect small and medium sized muscular arteries.

Rare

Any organ

Unknown cause

Results in aneurysms, thrombosis or aneurysm rupture with hemorrhage, organ ischemia or infarction.

Skin abnormalities may present. Rash, skin ulcers, peripheral neuropathy (pain,tingling,numb,weakness in hands and feet)

Question 31

Takayasu’s Arteritis

aka

The pulseless disease

Answer 31

Inflammation in the walls of the largest arteries in the body. Aorta and branches. Causes arterial walls to thicken and become narrow over time.

Female>male
Young women or teenage girls

Weak or loss of pulse

Symptomatic: dizziness, headache, fainting, weakness/fatigue, chest pain, HTN, heart attack, stroke.

Diagnosed by angio showing a tubular narrow large arteries.

Question 32

Buerger’s disease

Aka

Thromboangitis obliterans

Answer 32

Inflammation of arterial wall resulting in vessel thrombosis

Associated with heavy cigarette smoking.

Usually males < 40yrs old

Associated with collagen vascular syndromes such as rheumatoid arthritis and lupus.

Corkscrew appearance on angio

Dec or absent pulse may occur

Small fixed vessel obstruction. With distal artery occlusion in fingers and toes. Patient may have ulcers, gangrene, or digit amputation.

Question 33

Kawasaki disease

Answer 33

In children

Initial rash and fever. Late stage can cause inflammation of vessel walls

Coronary artery involvement
May become aneurysmal, thrombus

Question 34

Foot pump

Answer 34

Also return blood.