Arterial UE Flashcards
Subclavian a becomes axillary a at
1st rib
4 branches of subclavian
- Vertebral -1st
- Thyrocervical-
- Internal thoracic (internal mammary)
- Costocervical a.
Brachial a bifurcates into radial and ulnar a at
Antecubital fossa
Radial a travels lateral arm. And terminates into
Gives off branch in hand to form
Deep palmar arch.
Superficial palmar arch.
Radial artery joins deep palmar branch of ulnar a and terminates at deep palmar arch.
Ulnar artery travels medically and terminates at
Gives off deep palmar branch.
Superficial palmar arch.
Predominate source of blood to hand
Ulnar artery
Avoid venous flow via
Valsalva maneuver. Light prox compression.
Subclavian a waveform best obtained by _________ approach
Infraclavicular
Axillary a vest obtained at
Inferior junction if arm and torso (axillary region or armpit)
Brachial a runs down upper arm at ______ aspect of upper arm or antecubital fossa
Medial
Radial artery
Ulnar artery
Thumb side of wrist. Use light pressure.
Pinky side
Waveforms
Tri and Bi are normal.
Mono blunted round wave can indicate proximal stenosis or occlusion.
BP >20 mmhg
Plethysmography
Cuff placed in arm and forearm.
Vol displacement in cuff during cardiac chcke.
Amount of air displaced with each beat.
Avoid movement
40-65mmhg
Segmental pressure
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.
Pressure of >|= 15-20mmhg difference in bilateral brachial suggests
> 50% stenosis in subclavian, axillary, or brachial.
Upper arm and forearm should not have a difference of
> 20mmHg
Radial and ulnar pressures should be within ____mmHg of each other
10
Photoplethysmography PPG
Light absorption. Used diodoid.
Evaluates fingers
Patient with cold hands can show dampened waveforms
Tardus parvus all the way down right arm =
Innominate or brachiocephalic stenosis.
Thoracic Outlet Syndrome TOS
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.
Raynaud disease (Primary raynauds)
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
Raynaud’s Phenomenon (secondary raynauds)
Cold sensitivity with a fixed arterial obstruction
PPG low amplitude and rounded.
More serious than Raynaud’s disease. Can lead to ulcer and gangrene.
Palmar arch patency
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
Standard Allen test (palmar arch patency) May be unreliable
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.
Modified Allen test
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.
If there’s a complete arch, even with radial artery stenosis, blood flow would still return because ulnar artery takes over.
True
Radial artery harvest contraindications
Ischemic digits
Digit vasospastic disorder
Atherosclerotic occlusive disease in arms
Sclerotic or small radial artery.
Vasculitis
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
Giant cell Arteritis aka Temporal Arteritis
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
Polyarteritis Nodosa
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)
Takayasu’s Arteritis
aka
The pulseless disease
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.
Buerger’s disease
Aka
Thromboangitis obliterans
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.
Kawasaki disease
In children
Initial rash and fever. Late stage can cause inflammation of vessel walls
Coronary artery involvement
May become aneurysmal, thrombus
Foot pump
Also return blood.
