Chapter 11: Indirect Assessment of Arterial Disease Flashcards
A series of maneuvers testing the digital perfusion of the hand while compressing and releasing the radial and ulnar arteries
Allen test
The ratio of ankle systolic pressure to brachial systolic pressure
ankle-brachial index
pain in muscle groups brought on by exercise or activity that recedes with cessation of activity; can occur in the calf, thigh, or buttock
claudication
An indirect physiological test that detects changes in back-scattered infrared light as an indicator of tissue perfusion
photoplethysmography
an indirect physiologic test that measures the changes in volume or impedance in a whole body, organ, or limb
plethysmography
vasospasm of the digital arteries brought on by exposure to cold; can be caused by numerous etiologies
Raynaud’s Disease
Pain in the extremity without exercise or activity, thus, “at rest”; can occur in the toes, foot, or ankle area
Rest pain
Compression of the brachial nerve plexus, subclavian artery, or subclavian vein at the region where these structures enter or exit the thoracic cavity
Thoracic outlet syndrome
Intermittent claudication is located in the _____, _____, _____, _____.
buttock, thigh, hip, calf
Intermittent claudication and exercise.
always
Intermittent claudication is relieved by ______.
stopping
Spinal stenosis is located in the ____, _____, ______, and ____.
buttock, thigh, hip, calf
Spinal stenosis and exercise.
yes, but also with standing
Spinal stenosis is relieved by _____.
sitting, flexing, and moving spine
Herniated disc is located _____.
radiates down leg
Herniated disc and exercise.
variable
Herniated disc is relieved by _____.
varies; aspirin or anti-inflammatories
Osteoarthritis is located in the ____, _____, and _____.
hips, knees, ankles
Osteoarthritis and exercise.
variable; not always produced
Osteoarthritis is relieved by _____.
varies; aspirin or anti-inflammatories
Ankle-Brachial Index >1.30
incompressible PAOD
Ankle-Brachial index 0.9-1.30
normal
ABI 0.75-0.89
mild paod
ABI 0.50-0.74
moderate PAOD
ABI <0.50
severe PAOD
ABI <0.35
tissue threatening PAOD
Doppler waveforms proximal to knee are ____.
multiphasic
Plethysmography waveforms exhibit a _____.
dicrotic notch
Pulse waveforms have a well-defined _____.
peak
Resting and postexercise ABIS are _____.
0.90-1.30
Single (wide) above knee cuff systolic pressure is ______ higher brachial.
equal to
High thigh (narrow) cuff systolic pressure > or equal to _____ abover higher brachial.
30 mm Hg
All pulse waveforms have ____ systolic upstroke.
short
Difference between adjacent limb segments is < or equal to ____ mm HG.
30
Difference between brachial systolic pressures is < or equal to ___ mm Hg.
20
Resting and postexercise digit-brachial indices are > or equal to ____.
0.90
< or equal to ___ mm Hg systolic pressure between above and below elbows
20
Gradient between brachial systolic pressures is < or equal to ___ mm Hg.
20
Pulse waveform and temperature normal recovery time < or equal to ___.
10 minutes
Peripheral arterial occlusive disease has an ABI less than ___.
0.90
Digital ischemia in the lower extremity has a TBI less than ___.
0.80
Digital ischemia in the upper extremity has a TBI less than ___.
0.90
diminished or flat digital PPG waveforms during provocative arm/shoulder maneuvers and the development of symptoms.
thoracic outlet syndrome
Raynaud’s disease has a DBI less than ____.
0.90
Positive Allen test with diminished digital waveforms during manual compression of radial or ulnar arteries
incomplete palmar arch
(radial/ulnar dependency)
Most common symptom of PAOD in the lower extremity
leg discomfort caused by activity
fatigue, or as a cramping, aching, or tiredness sensation; usually starts in calf, progressing to thigh and buttocks
intermittent claudication
In PAOD symptoms occur ____ to the disease process.
distal
correction requiring sitting or spinal flexure
spinal stenosis
Claudication distances decrease, symptom recovery time _____ as PAOD progresses.
increases
Rest pain
forefoot pain may be constant
patient recumbent, raising leg a foot or so above heart level will usually cause blanching of the skin on the foot, becomes red with dependency
elevation pallor/dependent rubor
first indication of aneurysmal disease
blueness of the toes
most common site for aneurysmal disease
popliteal level
___ % of all extrinsic compression-related symptoms in upper extremity.
95
Cold sensitivity is generally referred to as ______.
Raynaud’s phenomenen
Primary Raynaud’s origin
idiopathic
Secondary Raynaud’s origin
underlying disease process
coexisting clinical conditions for PAOD exam
stroke/ishemic attack
carotid artery disease
heart attack
coronary artery disease
hypertension
diabetes
lipid disorder
symptoms related to positional causes of arm fatigue/numbness/aching and/or symptoms related to cold sensitivity
upper extremity indications
How long should patient rest before starting a systolic pressures exam?
10-15 minutes
The width of the cuff should be at least __% wider than limb segment.
20
If the blood pressure cuff is too narrow:
falsely elevated pressure
If the blood pressure cuff is too wide:
falsely lowered pressure
Systolic pressure exam cuff should be inflated ___ mm Hg about flat point.
20
During systolic pressure exam deflate cuff slowly ___.
3 mm Hg/s
indicate overall severity of PAOD between heart and ankle level
ABI
calculated by dividing the highest systolic pressure at ankle level by the higher of two brachial systolic pressures
ABI
presence of differing ipsilateral resting normal and abnormal ankle pressures; associataion with potential cardiovascular problems
PAOD isolated to a single ipsilateral tibial artery
ABI must alter by at least ____ to be significant.
0.15
A normal drop of ___ mm Hg as blood flows from heart to distal segments of lower extremity; increase in amplitude of pulses distally
10
Normal resting ankle systolic pressure
50 mm Hg
Normal resting ABI
0.90
indications of calcific vessels
Doppler signal does not reappear at a clearly defined pressure; increases in amplitude with further cuff deflation
technique of elevating an extremity; valuable to determine healing potential of pedal lesion
Pole test
measuring systolic pressures segmentally at two or three levels more proximally and comparing waveforms
segmental limb systolic pressures
Drops greater than 30 mm Hg in distal pressure between adjacent segments indicate:
presence of obstruction proximally
In the upper extremity, the most common location for PAOD is:
subclavian level and proximal axillary
Lower extremity locations Doppler Waveforms
CFA
SFA
POP
Distal PTA and DPA
upper extremity locations Doppler waveforms
subclavian
axillary
brachial
distal radial
distal ulnar
exhibit a degree of flow reversal in late systole/ early diastole
bidirectional waveform
More reversal in flow relates to ____ resistance to flow.
greater
Normal progression of PAOD _____ flow energy distal to lesions
reduces
arteriolar bed cannot dilate further and blood flow into affected segment(s) begin to drop
critical stage PAOD
PVR inflation of cuff
65 mm Hg
relate to moment-to-moment changes in limb volume; difference between arterial inflow and venous outflow
PVR
Normal PVR waveform
brisk upstroke with well-defined peak
usually shows a “notch” on downstroke in early diastole, which then returns to baseline in a concave manner before onset of next cardiac cycle
dicrotic notch
Moderate to severe PAOD waveforms
delayed onset to peak, more rounded
Diastolic phase becomes ____ as PAOD progresses
convex
Severe PAOD waveforms
waveforms may be virtually flat with very low amplitude
operated by transmitting infrared light into tissue and detecting tissue variations in light reflected from underlying blood flow from a depth of 1-3 mm
PPG
associated with symptoms involving one or more digits or hand; symptoms or signs asymmetrical; often present with tissue loss; tend to be older; affect both men and women;
Secondary Raynauds
Etiology of secondary Raynaud’s disease
trauma
hands change color when exposed to cold
Primary Raynauds
For primary Raynaud’s testing the hands should be immersed in ice cold water for __ to __ seconds max.
30-40
uses PPG waveforms to indicate adequacy of hand perfusion from radial and ulnar arteries; necessary to establish contribution to digital perfusion before certain surgical procedures
Allen test
_____ is a valuable asset when examining patients with suspected PAOD.
indirect arterial testing
The combination of systolic pressures and pulse waveforms produces both ____ and _____ information on extremity blood flow.
quantitative
qualitative
Which statement about intermittent claudication is FALSE?
a. It is generally described as pain with exercise that is relieved by rest
b. It can be asymptomatic at rest
c. ABI values consistent with claudication are generally between 0.5 and 0.8.
d. The amount of activity that produces the symptoms varies from day to day
c
Which type of disease is associated with blueness of the toes?
aneurysmal disease
Which of the following is associated with vasospasm and digital color changes due to an underlying process such as scleroderma or trauma?
a. primary Raynaud’s phenomenon
b. thoracic outlet syndrome
c. secondary Raynaud’s phenomenon
d. thromboangiitis obliterans
c
Which of the following would be considered risk factors for the development of PAOD?
a. history of smoking
b. coexisting clinical conditions such as TIA, CAD, hypertension, and diabetes
c. family history of cardiac and/or peripheral vascular disease
d. all of the above
d
Which method is most commonly used to calculate ABI?
the highest pressure at the ankle divided by the highest systolic pressure of the right or left brachial artery
Progression of PAOD can be established on follow up of patients by physical examination and clinical history because the patient may describe all of the following EXCEPT:
a. diminution of walking distance
b. increase of recovery time
c. skin and nail changes
d. resolution of pain by changing position
d
Severe PAOD can be suspected with all the following EXCEPT:
a. leg pain while sitting
b. skin discoloration and scaling
c. claudication pain after less than a 50 ft walk
d. constant forefoot pain
a
Thoracic outlet syndrome can include all of the following presentations EXCEPT:
a. pain with arm in neutral position
b. neurologic pain
c. edema of the arm and forearm
d. pain with arm elevated above the head
a
Which of the following is NOT a method to obtain arterial waveforms from the extremities or digits?
a. plethysmography
b. photoplethysmography
c. CW Doppler
d. segmental systolic pressure
b
To ensure accuracy of data, particularly for recording segmental systolic pressures, how long should the patient be allowed to rest?
10-15 minutes
What is the appropriate size for a blood pressure cuff to be used on an extremity to ensure the accuracy of data obtained for systolic pressure determination?
20% wider than the diameter of the limb segment
All the following can result in inaccurate systolic pressure measurements in the lower extremities EXCEPT:
a. the cuff is too narrow
b. the dorsalis pedis artery is used to listen to the signal
c. the limb segment is elevated above the heart
d. the deflation rate is too fast
b
What will the use of a 4-cuff versus a 3-cuff method to estimate arterial disease in the lower extremities help determine?
whether disease is present at the iliofemoral level
Which of the following are clear diagnosis criteria to estimate disease between two limb segments when using systolic pressure determination?
a. a drop of more than 30 mm Hg between the proximal and immediate distal segment
b. an increase of more than 30 mm Hg between the proximal and immediate distal segments
c. a drop of 50 mm Hg between the proximal and immediate distal segments
d. an increase of 50 mm Hg between the proximal and immediate distal segments
a
Which of the following is NOT a common method to induce symptoms with exercise in a patient suspected to have arterial insufficiency but relatively normal results at rest?
a. using a treadmill for walking with a set protocol
b. having the patient walk at own pace until symptoms occur
c. having the patient perform heel raises until symptoms occur
d. raising the limb above the heart while the patient is supine on the examination table
d
Which of the following is NOT one of the main advantages of pulse volume recording (PVR)?
a. records overall segment perfusion
b. can give data even with calcified arteries
c. is easy and quick to perform
d. provides quantitative values
d
Which of the following would most likely be used to describe CW Doppler waveforms that occur distal to a hemodynamically significant stenosis?
a. triphasic
b. biphasic; bidirectional
c. monophasic; moderate/severe
d. multiphasic
c
When the arteriolar bed cannot dilate further and blood flow to the extremity is reduced due to proximal arterial disease, what symptoms will the patient likely experience?
forefoor pain at rest
What is the main pitfall in the interpretation of PVR waveforms and other physiologic data?
inability to differentiate between stenosis and occlusion
What is the most convenient (and reliable) technique to obtain digital pressures while using a small digital cuff?
PPG
What is the most convenient technique to record changes of arterial insufficiency with thoracic outlet syndrome with a specifiic (and sometimes tailored_ set of maneuvers?
PPG on a digit
What is the typical skin color changes (in the hands and fingers) associated with Raynaud’s disease from room temperature to exposure to cold temperautre and ending with rewarming?
white, blue, red
The Allen test should be performed before all the following procedures EXCEPT:
a. creation on arteriovenous fistula
b. creation of dialysis access
c. harvest of the cephalic vein for bypass
d. harvest of the radial artery for a coronary bypass
c
The Allen test is typically performed by placing a PPG sensor on the middle or index finger to record digital perfusion while:
the radial and ulnar arteries are compressed sequentially
Using PPG sensor on a digit demonstrating signs of increased vasospasm from primary Raynaud’s disease, what characteristic will the waveform typically display?
a peaked pulse on the anacrotic portion
Most often, symptoms of arterial disease are described as “intermittent” claudication because the symptoms occur ____.
with activity
Symptoms observed or described with intermittent claudication can determine the site of disease because the disease is _____ to the site of symptoms.
distal
Lower extremity symptoms that require sitting and/or spinal flexure to relieve is usually associated with _____.
spinal stenosis
Elevation pallor and dependent rubor is usually observed with _____ arterial disease.
severe peripheral
The cause of primary Raynaud’s disease is _____.
idiopathic
PAOD in the upper extremities occurs in _____ of all cases.
less than 5%
Nonimaging, indirect tests for arterial disease help determine overall limb _____ and serve as an indicator of the functional status of the limb.
perfusion
The ideal positioning of patients for indirect arterial testing should take great care that all extremities are not elevated above ____.
the heart
For recording of accurate segmental systolic pressures, it is important not only to ensure the cuff is appropriately sized for the limb segment but also to allow the patient to _____ before beginning the exam.
rest
An ideal cuff deflation rate for accurately determining the return of Doppler signal when measure systolic pressure at any segment should be approximately ____.
3 mm Hg
The lowest limit of an ABI to be considered within normal range at rest is _____.
0.9
The presence of differing ipsilateral resting normal and abnormal ankle pressures indicates that PAOD is isolated to ______.
single tibial artery
A change in ABI of _____ between repeat studies indicates a significant change associated with worsening of PAOD.
0.15
When recording pressures from sites proximal to the ankle, the vessel (PTA or DPA) with the ______ pressure is used to obtain the Doppler signal.
higher systolic
Systolic pressures are invalid when the underlying artery is _____ and incompressible.
calcified
Under normal conditions (absence of disease), the high-thigh pressure using a 4-cuff method will usually be at least _____ greater than the normal brachial pressures.
30 mm Hg
In the upper extremities, using segmental pressure as diagnostic criteria, significant disease will be likely when a drop of at least _____ is recorded between two consecutive segments (from proximal to immediately distal segments)
20 mm Hg
ABIs returning to resting values more than 10 minutes postexercise are a good indication of _____.
PAOD at multiple levels
Independent of the increasing discussion about the “correct” nomenclature to be used to describe continuous-wave Doppler waveforms, a normal CW Doppler waveform from an artery of the lower extremity should be ______.
bidirectional
The typical cuff inflation for segmental pulse volume recording (PVR) is _____.
55-65 mm Hg
CW Doppler and PVR waveforms analysis are examples of ______ criteria for the diagnosis of arterial disease.
qualitative
An abormal PVR waveform demonstrates delayed onset to peak, rounding and flattening of the peak, and a diastolic component that becomes _____.
convex
A normal TBI should be at least ____.
0.8 or greater
A positive TOS study will result in the PPG waveform becoming _____ as well as the patient developing systems/.
flattened
Testing for increased sensitivity to cold using immersion in ice water should only be used in patients with suspected ____.
primary Raynauds disease
A patient with left thigh claudication will most likely have disease present at which of the following levels?
a. aortic occlusive disease
b. left iliofemoral disease
c. aortoiliac occlusive disease
d. left superficial femoral artery disease
b
A patient with thigh and calf pain that is associated with exercise and also with standing that can be relieved with sitting or by moving into a different position is most likely due to:
spinal stenosis
What is a contraindication to immersing the hands in ice water to detect cold sensitivity?
secondary Raynaud’s
What is the maximum time for digit temperatures to return to pre-cold water immersion levels, to rule out cold sensitivity?
< 10 minutes
A notch on the upstroke (anacrotic) portion of a finger pulse waveform is consistent with which clinical condition?
a. ipsilateral brachial artery occlusion
b. vasospasm
c. ipsilateral dialysis fistula
d. vasodilation
b
Measuring the systolic pressure with the point of measurement at the same horizontal level as the heart helps avoid artifacts due to:
hydrostatic pressure
What is the normal drop in mean arterial pressure from the heart to the ankle?
10 mm Hg
Which of the following statements about the four-cuff versus three-cuff method of determining segmental pressures in correct?
a. the four-cuff method allows the separation of iliofemoral disease from superficial femoral artery disease
b. the four-cuff method allows for separation of superficial femoral from popliteal level disease
c. The four-cuff method allows for lower thigh cuff inflational pressures
d. The four-cuff method allows for more accurate determination of pressure because the narrower cuffs used are the same size as the width of the leg.
a
Arterial occlusive disease in the upper extremities is most likely found in which arteries?
subclavian and proximal axillary
A brachial blood pressure difference greater than 20 mm Hg is associated with which of the following?
a. A >50% diameter reduction in either the subclavian or proximal axillary arteries
b. A >75% diameter reduction in only the subclavian arteries
c. A >50% diameter reduction in only the subclavian arteries
d. A >75% diameter reduction in either the subclavian or proximal axillary arteries
d
A treadmill exercise stress test is typically conducted using the following parameters:
0-10% grade and 1 to 2 mph
Contraindications to treadmill exercise include all of the following EXCEPT:
a. arrythmias
b. hypertension with systolic pressures >180 mm Hg
c. Age >75 yeras
d. chest pain
c
Which of the following is a technique that can be used to reduce interference from adjacent veins during acquisition of Doppler waveforms?
a. elevate the patient’s legs, such that their ankles are higher than the level of their heart
b. Have the patient hold their breath for a few cardiac cycles
c. Inflate a cuff distal to 30 mm Hg to the artery being insonated
d. Have the patient take a long slow inspiration during the capture of the arterial waveforms.
b
What is the proper transducer angle to use while obtaining a Doppler waveform?
45 degrees to the skin surface
Which of the following statements about flow reversal in a peripheral artery is incorrect?
a. no flow reversal is present in low resistance limbs
b. the greater the resistance to flow, the greater the reverse flow component
c. An incompetent aortic valve may impact flow reversal
d. Flow reversal is maintained in the presence of a functioning dialysis fistula
d
Pulse volume recordings reflect:
total perfusion in the underlying segment under the cuff
Which of the following statements about photoplethysmography is incorrect?
a. they detect underlying blood flow as 1 to 3 mm depths.
b. they detect total limb blood flow
c. They cannot be calibrated
d. They transmit an infrared light into the tissue
b
Which of the following positions is not sued when testing for thoracic outlet syndrome?
a. supine with arms at the side
b. the position that elicitis symptoms
c. the arms abducted rearward
d. the Adson maneuver
a
What is the percentage of normal, asymptomatic individuals that can elicit a positive finding on a TOS test?
60%
Which of the following is not a possible etiology for secondary Raynaud’s?
Takaysu’s arteritis
Pain in large muscle groups caused by activity; pain may be described as fatigue, cramping, aching, or tiredness; usually occurs in calf, thigh, or buttocks
Intermittent claudication
Site of symptoms of intermittent claudication occurs ____ to the site of disease.
distal
True claudication symptoms are relieved with _____.
quiet standing
Diseases that may mimic claudication include:;
spinal stenosis
herniated disk
osteoarthritis
What is rest pain?
pain in foot while patient is lying down; represents increasing severity of disease
Thickening of toenails and loss of toe hair
skin discoloration and scaliness
elevation pallor/dependent rubor
ulceration/gangrene
Advanced PAOD
Blue toes may indicate:
aneurysmal disease
It is important to let the patient rest for ______ minutes before beginning exam.
10-15
Cuff width should be ____ wider than the diameter of underlying limg.
20%
If the cuff is too narrow:
falsely elevated pressure
if the cuff is too wide
falsely lower pressure
For ABIs, cuffs are placed at:
upper arm
ankle
For multilevel lower extremity pressures, cuffs are placed:
upper arm
thigh
calf
ankles
Doppler signal is obtained ____ to the cuff/
distal
The cuff should be inflated ___ mm Hg above point where signal disappears.
20
Cuff should be deflated at a rate of about ___ mm Hg/s
3
Systolic pressure ratios calculated by:
dividing highest systolic ankle pressure by the higher of the two brachial systolic pressures
ABI >1.30
incompressible
ABI 0.90-1.30
normal
ABI 0.75-0.89
mild
ABI 0.50-0.74
moderate
ABI <0.50
severe
ABI <0.35 t
tissue threatening
Normal ABI is about ___.
1.0
A change of ____ between repeat studies in considered significant.
0.15
_____ ABI values correspond to worsening PAOD.
Lower
Excessibly high ABI values typically correspond to:
calcified arteries
Systolic pressures usually _____ as blood flows distally in the lower extremity.
increase
Pressure drop ____ mm Hg indicates presence of proximal obstruction
> 30
Any reduction is distal pressure should be _______ mm Hg between adjacent segmant.
<30
Doppler waveforms proximal to knee are _____.
multiphasic
Plethysmography waveforms exhibit a ______.
dicrotic notch
Resting and postexercise ABIS are _____.
0.90-1.30
Resting and postexercise toe-brachial indices are ____.
> 0.80
Single (wide) above knee cuff systolic pressure _____ than brachial.
equal to or higher
High thigh (narrow) cuff systolic pressure > 30 mm Hg _____ higher brachial.
above
Difference between adjacent limb segments is ______ mm Hg.
less than or equal to 30
Difference between brachial systolic pressures is _____ mm Hg.
less than or equal to 20
ABI that returns to pre-exercise level within ___ minutes associated with single-level disease.
5
ABI that returns to pre-exercise level _____ minutes associated with multilevel disease.
> 10
Normal Doppler waveforms are _____.
multiphasic
PAOD reduces flow energy ____ to the lesion.
distal
Normal PVR waveforms should include:
Rapid upstroke with well-defined peak
Notch on downstroke in early diastole
return to baseline through remainder of diastole
Moderate to severe disease PVR waveforms:
delayed onset to peak
round peak
diastolic phase becomes convex (bows out rather than toward the baseline)
Normal TBI
greater than or equal to 0.8
Toe pressure of ___ mm Hg indicates adequate pressure for healing.
50
PAOD occurs in the upper extremity typicall as _____ and ______.
positional extrinsic compression (TOS syndrome)
cold related vasospasm (Raynaud’s disease or phenomenon)
Numbness, aching, or tiredness with positional changes of the shoulder
Thoracic outlet syndrome
Primary raynaud’s has an _____ etioloy.
idiopathic
Secondary Raynaud’s is associated with:
underlying condition such as scleroderma or trauma
If PAOD is found in upper extremity, it is most likely in the _____ and _______ arteries.
subclavian
proximal axillary
> ___ mm Hg difference in brachial systolic pressures indicates presence of subclavian artery stenosis.
20
Normal DBI
> or equal to 0.9
Patients with suspected ________ should not have hands immersed in ice water.
secondary Raynaud
Used to determine digital perfusion prior to certain surgical procedures
the Allen test
