Chapter 13: Duplex Ultrasound of Upper Extremity Arteries Flashcards
a vasospastic disorder of the digital vessels
Raynaud’s syndrome
A form of large vessel vasculitis resulting in intimal fibrosis and vessel narrowing
Takaysu’s arteritis
The superior opening of the thoracic cavity that is bordered by the clavicle and first rib; the subclavian artery, subclavian vein, and brachial nerve plexus pass through this opening
thoracic outlet
A sudden constriction of a blood vessel that will reduce the lumen and blood flow rate
vasospasm
Upper extremity arterial disease occurs in only about __% of extremity ischemia.
5
Causes of upper extremity symptoms
mechanical obstruction at the thoracic outlet
embolism
trauma
digital artery vasospasm
digital artery occlusion
What percentage of extremity peripheral arterial disease do upper extremity arterial diseases represent?
5%
Which of the following is NOT a prominent etiology of arterial diseases in the upper extremities?
a. mechanical obstruction or compression at the thoracic outlet
b. embolism from various sources (including the heart)
c. vasoconstriction of digital arteries
d. diffuse atherosclerosis of the axillary or brachial artery
d
The right subclavian artery originates from the _______.
innominate artery
The left subclavian artery originate from the _____.
aortic arch
The first major branch of the aortic arch.
innominate artery
The innominate artery is also known as the ______.
brachiocephalic artery
The innominate artery divides into the ______ and the _____.
right common carotid artery
right subclavian artery
The retroesophageal subclavian artery is also known as the _____.
aberrant right subclavian artery
Right subclavian may originate directly from aorta distal to left subclavian artery and then pass posterior to esophagus to the right side
retroesophageal subclavian artery
arises from dilated segment of proximal descending aorta
Kommerells diverticulum
palsy of recurrent laryngeal nerve
Ortner’s syndrome
Second major branch from aortic arch
left common carotid artery
Third major branch from aortic arch
left subclavian artery
first major branches of both left and right subclavian arteries
vertebral arteries
Subclavian arteries exit through _____.
thoracic outlet
an extra rib as a result of an overdevelopment of a cervical spine vertebra transverse process; above first rib and just above clavicle
cervical rib
The subclavian artery turns into the _____ artery at the lateral margin of the first rib.
axillary
The axillary artery transitions into the _____ artery at level of inferior lateral border of teres major muscle.
brachial
Found in the upper arm passing posterior to the humerus
deep brachial artery
Most common upper extremity arterial anatomic variant
“high-takeoff”
radial artery originates in mid to upper arm instead of in or just distal to antecubital fossa
“high-takeoff”
The brachial artery divides into :
radial artery
ulnar artery
interroseus artery
continues at wrist deep to lateral flexor muscles of forearm
radial artery
The radial artery divides into two branches at the wrist
superficial palmar arch
deep palmar arc
gives origin to interosseous artery in proximal forearm before passing deep to medial forearm flexor muscles
ulnar artery
courses toward wrist adjacent to flexor carpi ulnaris tendon before crossing wrist where passes deep to hook of hamate bone
ulnar artery
trauma to ulnar artery in area of hamate bone
results in:
arterial degeneration
thrombus formation
potential occlusion
Hypothenar hammer syndrom
Give origin to metacarpal arteries
superficial and deep palmar arch
give origin to paired digital arteries
metacarpal arteries
What is a dilated segment of the proximal descending aorta which may give rise to the takeoff of an aberrant subclavian artery?
Kommerell’s diverticulum
Which of the following is NOT a common site for compression of the subclavian artery?
a. compression between the first rib and scalene muscle
b. compression between the clavicle and first rib
c. compression by the brachial plexus
d. compression by the pectoralis minor
c
Which of the following is/are a potential consequence(s) of compression of the subclavian artery at the thoracic outlet?
a. thrombosis
b. stenosis
c. aneurysm
d. all of the above
d
Injury of what artery may result in hypothenar hammer syndrome>
the ulnar artery at the wrist
intermittent digital ischemia from cold exposure or emotional stimuli
Raynaud’s syndrome
condition of abnormal digital artery vasospasm resulting in pain and a characteristic pallor of the digits followed by cyanosis and hyperemia upon rewarming
Primary Raynaud’s syndrom
also known as Raynaud’s phenomenon
Secondary Raynaud’s syndrome
Most common systemic condition of Secondary Raynaud’s syndrome
scleroderma
The majority of digital artery occlusive disease originates ____ to the wrist.
distal
compression of structures in thoracic outlet
thoracic outlet syndrome
symptoms of TOS
pain
weakness
muscle atrophy
TOS occurs primarily in _____ patients.
younger
Ulcerated lesions or aneurysm can cause _____ which serve as a source of _____ embolization
thrombus formation
distal
Unilateral digital artery occlusion is suggestive of ______ embolic source.
proximal
The _____ artery is the first major branch of the aortic arch and divides into the right common carotid artery and subclavian arteries.
innominate
On the left, the ______ artery arises directly from the aortic arch in 4% to 6% of patients.
vertebral
The artery resting between the biceps muscle anteriorly and triceps muscle posteriorly is the _____ artery.
brachial
The artery, which lies deep to the pectoralis major and minor, is the _____ artery.
axillary
A high takeoff occurs most commonly as a variant of the _____ artery.
radial
The interosseous artery commonly takes off from the _____ artery.
ulnar
Arterial duplex ultrasound rules out clinically significant injuries of the upper extremity arteries, ______ to the axillary crease.
distal
upper extremity atherosclerosis in absence of renal failure or diabetes
arterial occlusive disease
Arterial occlusive disease is generally confined to ___.
proximal subclavian artery
reversal or bidirectional flow in ipsilateral vertebral artery
subclavian steal syndrome
stenosis or occlusion of subclavian artery as manifested by blunted proximal subclavian artery velocity waveforms along with reversed or staccato flow in vertebral artery
subclavian steal syndrome
autoimmune disorder that affects arteries of aortic arch, visceral abdominal aorta, and pulmonary arteries
Takayasu’s arteritis
Takayasu’s arteritis most commonly affects_____
women in 20s and 30s
Type I Takayasu’s arteritis
branches of the aortic arch
Type IIa Takayasu’a arteritis
ascending aorta
aortic arch and branches
thoracic descending aorta
Type III Takayasu’s arteritis
thoracic descending aorta
abdominal aorta
renal arteries
Type IV Takayasu’s arteritis
abdominal aorta
renal arteries
Type V Takayasu’s arteritis
combined features of types IIb and IV
acute phase symptoms of Takayasu’s arteritis
fever
malaise
arthralgias
myalgias
elevated erythrocyte sedimentation rate
elevated C reactive proteins
Primary treatment of Takasayu’s arteritis
steroids
immunosuppressive medications
Giant cell arteritis affects:
caucasion women over 40
Giant cell arteritis can affect the ______, ______, and ______.
opthamolic
subclavian
axillary
Ultrasound findings acute phase of axillary artery
thickened hypoechoic arterial wall due to edema; evidence of flow restriction
Treatment for Giant Cell Arteritis
anti-inflammatory medications
immunosuppresant medications
Buerger’s disease is also known as ______.
thromboangiitis obliterans
primarily involves small vessels of hands and feet; seen in cigarette smokes under 50 years
Beurger’s disease
Which arteries are visualized with the sternal notch window and the infraclavicular and supraclavicular approaches?
the subclavian arteries
The evaluation of the axillary artery by duplex is often accomplished with the arm in the _______.
“pledge position”
What arteries need to be examined during an upper arterial exam?
subclavian
axillary
brachial
radial
ulnar
When irregularities are noted sonographer should use a ______ to document prestenotic PSV, PSV at stenosis, documentation of poststenotic turbulence.
stenotic profile
windows of insonation of origin of subclavian artery
sternal notch
supraclavicular
infraclavicular
crosses under clavicle and first rib
subclavian artery
Using the sternal notch window, the origin of the subclavian artery is usually first identified with color Doppler in a _____ view.
transverse
With Doppler, all arteries in the upper extremities should, under normal conditions, exhibit ____ resistance.
high
Under normal conditions, what is the flow velocity range of the arteries in the forearm?
40 to 60 cm/s
What is the normal upper extremity waveform?
multiphasic, sharp systolic peak, followed by a brief period of diastolic flow reversal and then minimal continued forward flow in diastole
Upper extremity arteries are ____ resistance.
high
Normal PSV range for subclavian arteries
80 to 120 cm/s
Normal PSV range for forearm arteries
40 to 60 cm/s
increased PSVs with loss of end systolic reverse flow
postenotic turbulence
dampened distal arterial waveforms
signs of stenosis in upper arm
A greater than 50% stenosis in the upper arm, would cause the PSV ratio to be ____.
greater than 2
What is indicated by a triphasic waveform distal to a high PSV?
falsely elevated proximal PSV
What is indicated by a monophasic distal waveform
proximal lesion hemodynamically significant
documented by demonstrating the absence of flow within the lumen of the artery by color and spectral Doppler
occlusions
What can help increase blood flow in the upper extremity to help with an exam?
exercising or warming the extremity
To assist in the visualization of the relative small caliber arteries in the forearm, the sonographer may use _______ of the arm to increase blood flow.
exercise or warming
permanent localized dilation in an artery
aneurysm
Aneurysms have to meet the criteria of ____ or greater increase in diameter of the artery.
50%`
Subclavian artery aneurysms often occur with _____.
Arterial TOS
Well known etiologies of aneurysms in the axillary, brachial, radial, and ulnar arteries.
atherosclerosis and trauma
repeated use of palm of hand as a hammer
Hypothenar hammer syndrome
The most common system condition resulting in secondary Raynaud’s syndrome is _____.
scleroderma
Digital artery necrosis associated with Raynaud’s symptoms will rarely be seen with ______ Raynaud’s syndrome.
secondary
Provocative maneuvers demonstrating subclavian artery compression at the thoracic outlet may occur in 30% of _____ individuals.
normal
Unilateral digital ischemia should prompt the sonographer to look for a source of _______ from more proximal arteries.
embolization
Duplex ultrasound has been shown to be an effective means of evaluating for upper extremity ______, even though computed tomographic arteriography or direct surgical exploration is currently the standard of car.
vascular injuries
Clinically, significant stenosis or occlusion of upper extremity arteries from atherosclerosis is typicalled confined to the ______ artery.
proximal subclavian
Symptoms of fever, malaise, arthralgia, and myalgia are not uncommon in the ____ phase of Takasayu’s disease
acute
Immunosuppressant and anti-inflammatory medications are the primary treatement for several forms of ______.
Giant cell arteritis
A definite diagnosis for Buerger’s disease is best achieved with _____.
angiography
When evaluating an aneurysm, it is important to visualize the vessel in a true _____ plane to not falsely overestimate the diameter.
axial
With what condition are aneurysms of the subclavian arteries often associated?
thoracic outlet syndrome
What is the landmark that marks the transition from the axillary artery to the brachial artery?
inferolateral border of the teres major muscle
How is primary Raynaud’s syndrome distinguished from,m secondary Raynaud’s syndrome or Raynaud’s phenomenon?
There are no underlying diseases
Although rare, digital artery occlusion from embolization may occur. Which of the following is NOT a predominant source of embolization?
a. subclavian artery aneurysms
b. stenosis of proximal upper extremity arteries
c. fibromuscular diseases of arteries of the forearm
d. thromboangiitis obliterans
d
To efficiently assess perfusion and/or vasospasm of digital arteries, how should one record waveforms obtained with PPG?
pre- and post- cold immersion
Compression of structures at the thoracic outlet may happen with all of the following EXCEPT:
a. hypertrophy of the scalene muscle
b. hypertrophy of the pectoralis minor muscle
c. the presence of a cervical rib
d. the presence of abnormal fibrous bands
b
Which statement regarding compression of the brachial plexus and vascular structures at the thoracic outlet is FALSE?
a. Compression of either will give similar symptoms
b. Compression of either cannot be easily confirmed by provocative maneuvers
c. compression of both often occurs concomitantly
d. Confirmation of neural symptoms is best done by electromyography
c
How is “arterial minor” form of thoracic outlet syndrome defined?
intermittent compression of the subclavian when the arm is raised overhead
Which condition is associated with significant stenosis or occlusion of arteries of the arm and/or forearm from atherosclerosis?
a. diabetes and/or renal failure
b. coronary artery disease
c. peripheral arterial disease
d. systemic diseases
a
A 47-year old male smoker presents to the vascular lab with ulceration of his fingertips. What disease process should be suspected in this patient?
Buerger’s disease
Which form or arterial inflammation can affect the ophthalmic artery as well as the subclavian or axillary?
Giant cell arteritis
What is the most significant difference between giant cell arteritis and Takayasu’s disease when both affect the subclavian artery?
the age of the patient
First major artery of the aortic arch
Brachiocephalic artery
The brachiocephalic artery divides into _____ and _____ arteries.
right common carotid
right subclavian
Arises directly from aortic arch as third major branch
left subclavian artery
First major branch from both subclavian arteries
vertebral arteries
Subclavian arteries exit chest through ______
thoracic outlet
originates at the lateral margin of the first rib; lies deep to pectoralis major and minor muscles
axillary artery
At elbow level, the brachial artery divides into _____, _____, and ______ arteries.
radial
ulnar
interosseous
The radial artery branches into _____ and ______/
superficial and deep palmar arches
Gives rise to interosseous artery; passes deep to forearm flexor muscles; courses toward wrist following ulnar; terminates as the superficial palmar arch
ulnar artery
Upper extremity artery branches
subclavian
axillary
brachial
radial
ulnar
Windows for insonation of the sublclavian arteries
sternal notch; supraclavicular; infraclavicular
Normal upper extremity waveform
multiphasic
sharp systolic peak
brief period of diastolic flow reverasal
minimal continued forward flow in diastole
Normal PSV varies from _____ cm/s in subclavian
80 to 120
Normal PSV varies from ______ cm/s in brachial, radia, and ulnar arteries.
40 to 60
Permanent localized dilation resulting in 50% increase in diameter of an artery compared to adjacent normal artery
aneurysm
arterial degeneration of ulnar artery as it passes deep to hook of hamate bone; associated with repeated used of palm of hand as a hammer
Hypothenar hammer syndrome
abnormal digital artery vasospasm; results in pain and color changes; anatomically, digital arteries appear normal; rarely results in tissue damage
Primary Raynaud’s syndrome
underlying disease process responsible for symptoms; patients tend to develop occlusive lesions; associated with tissue necrosis
Secondary Raynaud’s syndrome
Impingement of the neurovascular bundle at the thoracic outlet
thoracic outlet syndrome
Significant atherosclerotic disease in the upper extremity involves the:
proximal subclavian artery
Arterial occlusive disease occurs most often in the ___ subclavian artery.
left
autoimmune disorder that affects the arteries of the aortic arch and visceral abdominal aorta
Takayasu’s arteritis
Giant cell arteritis can involve _____, ______, ______, and ______ arteries.
opthalmic
subclavian
axillary
superifical temporal
primarily involves small vessels of hands and feet; seen in smokers under 50
Buerger’s disease
