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Vascular 2 > M5&6: Peripheral Arterial Part 1 & Indirect Testing > Flashcards

M5&6: Peripheral Arterial Part 1 & Indirect Testing Flashcards

1
Q

risk factors for PAD that can be related to life style

A 
HTN
diabetes
hyperlipidemia
smoking
obesity
physical inactivity
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2
Q

risk factors for carotid disease related to the heart and blood

A

homocysteine (a.a produced in liver)
high levels of C-reactive protein (made by the liver)
coronary artery disease
previous TIA or stroke

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3
Q

genetic and/or uncontrollable risk factors for carotid disease

A 
sex - male
age
hypercholesterolemia
genetic predisposition/fam Hx
patent foramen ovale
radiation
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4
Q

why is diabetes a risk factor for PAD

A
  • atherosclerosis is more common at a younger age in diabetics
  • high incidence of occlusive disease in the pop and tibial arteries
  • medial wall Ca ++ in the legs is common
  • high incidences of gangernous changes leading to amputation
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5
Q

skin changes seen w/ PAD

A 
pallor
rubor
dependant rubor
cyanosis
temperature changes
ulcers
gangrene
trophic changes
capillary refill time
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6
Q

describe rubor and dependant rubor

A

dark reddish colour or discolouration from dilated or damaged vessels

dependant: limb takes on pallor when elevated but is abnormally red with hanging dependant

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7
Q

why does cyanosis occur

A

[ ] of deoxygenated hemoglobin

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8
Q

where do ulcers usually form

A

over the tibial area

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9
Q

what do trophic changes refer to

A

shiny, scaly skin, thick toe nails, loss of hair… due to lack of nourishment

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10
Q

what is capillary refill time

why would it be increased

A

time it takes for colour to return to skin when pressure is applied and then released…. should return immediately

poor arterial blood supply

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11
Q

how are arterial pulses graded

what kind of pulse do aneurysms have

A

0-4 +
0 = no pulse
4 = bounding

bounding

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12
Q

what may be heard on auscultation w/ PAD

when is it not heard

how it it graded

A

bruits - abnormal frequency sound due to a significant stenosis…

if vessel is > 90% stenosed because trickle flow happens

1+ - 3+ (mild to severe)

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13
Q

describe claudication

cause

A

muscle pain that occurs w/ exercise and subsides with rest, intermittent and reproducible

lack of blood supply to a group of muscles

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14
Q

common sites for claudication

A

hip, thigh, butt, calf

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15
Q

if claudication is experienced, where is the disease location in reference to the affected muscle groups

A

disease is ALWAYS PROX to the affects muscle groups

(e.g. butt claud. = distal AO/iliac disease
thigh = distal external iliacs/CFA
calf = fem/pop disease)

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16
Q

describe ischemic rest pain

A

severe pain in the affected limb, usually affects the dorsum (top) of foot and toes, NOT relieved by rest

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17
Q

what does ischemic rest pain indicate

precursor to what

A

always an indicator of advanced multi-segment disease

limb loss unless theres treatment

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18
Q

when does ischemic rest pain usually occur during the day

why and what can relieve it

A

night…

limb is not dependent, relieved by lowering the foot or mildly exercising

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19
Q

what is the most sever symptom of PAD

A

necrosis

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20
Q

describe pseudoclaudication

A

pain caused by other factors (degenerative joint disease, spinal stenosis, herniated disc)

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21
Q

is pseudoclaudication reproducible w/ exercise testing

A

no

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22
Q

common patient HX w/ PAD

A 
exercise related claudication
rest pain
paralysis
paresthesia
poikilothermia
previous ulcerations/gangrene or therapeutic vascular procedures
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23
Q

most common location of obstructive atherosclerosis in LE

other common sites

A

SFA adductor canal/Hunters canal (distal SFA)… can be hard to see

bifurcations
pop artery

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24
Q

common cause of aneurysm in LE

common locations

A

trauma or atherosclerosis

AO (AAA)
femoral A
pop A

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25
Q

common cause of subclavian aneurysms

what can they cause

A

compress of the SA due to thoracic outlet syndrome

embolization to the distal arteries in the hand

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26
Q

what is hypothenar hammer syndrome

A

aneurysms in the ulnar A due to using hand as hammer…..

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27
Q

diameter of A w/ an aneurysm

how do we document them

A

-diameter of A increase by at least 50%

  • measure AP, outer wall to outer wall, in SAG and TRX
  • colour doppler
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28
Q

how does colour doppler help w/ an aneurysm

A
  • helps to outline the thrombus

- shows to and fro flow along the outer wall of the aneurysm

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29
Q

why do we do peripheral arterial duplex testing

A
  • look for stenosis or occlusion (can help w/ pre surgery/intervention)
  • evaluate bypass graft
  • look for aneurysm
  • follow up post surgery or to assess effectiveness of medical treatment
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30
Q

what pathology of the A wall can make a PA assessment hard

A

calcium deposits which will shadow

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31
Q

an ABI change of what value will warrant a LE, PA scan

A

decrease in ABI of > 0.15 compared to previous

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32
Q

common reasons for a PA scan of the UE

A 
BP difference > 20 mmHg
thoracic outlet syndrome
evaluate prior to dialysis access
cold sensitivity
raynaud's syndrome
33
Q

how should you document a suspected area of stenosis in the LE

A
  • measure lumen reduction in 2D, especially w/ hemodynamically significant stenosis
  • document highest velocity + PW prox and distal to disease
34
Q

why is it important to have colour gains set appropriately

A

if gain is too high, colour flow can obscure the true reduction of the lumen

35
Q

how do we assess UE arteries

A 
record 2D, colour and spectral images in SAG of:
innominate A (for R side)
prox SCA - probe supraclavicular
dis SCA - probe infraclavicular
Axillary A
brachial A
radial A (only spectral)
ulnar A (only spectral)
36
Q

normal PSV for UE arteries

A

SCA and AXA: 70-120 cm/s
BRA: 50-120 cm/s
RA and UA: 40-90 cm/s

37
Q

what may be more important than velocity to determines disease in the UE

A

changes in the waveform

38
Q

how far should you walk the SV proximal to a suspected stenosis

what should you show distal to the stenosis

A

within 2 cm

post stenotic turbulence and bruit if present

39
Q

what velocity ratio can we use w/ PAD

A

V2/V1 : V2 is the max PSV of a stenosis, V1 is the PSV of the prox normal segment

40
Q

normal lower extremity arterial waveforms have what characteristics

A

triphasic

could be biphasic w/o any visualized stenosis… so could be classified as normal… more important is the discovery of CHANGES from triphasic to biphasic

41
Q

should PSV be relatively uniform throughout an atria segment

A

yes

42
Q

mean PSV in LE arteries

A 
external iliac: 120 +/- 22 cm/s
CFA: 114 +/- 25 cm/s
SFA prox: 91 +/- 14 cm/s
SFA dist: 94 +/- 14 cm/s
pop A: 69 +/- 13 cm/s
43
Q

describe a biphasic waveform

A
  • strong forward flow in early systole/sharp upstroke
  • loss of flow in early diastole (no reversal)
  • decrease of late diastolic flow
44
Q

describe a monophasic waveform

A
  • decreased pulsatility and PSV
  • no reversed flow in late systole
  • may or may no have diastolic flow

THINK TARDUS PARVUS - distal to severe stenosis

45
Q

focal velocity increase of > or = what value indicates > 50% stenosis

A

> or = double of a prox norm arterial segment

46
Q

focal velocity increase of > or = what value indicates > 70% stenosis

A

> or = triple of a prox norm arterial segment

47
Q

what does a staccato waveform indicate

A

severe distal stenosis or occlusion

48
Q

if an artery is completely occluded and hard to identify, what can you use to help

A

use the flow in an adjacent vein as a guide to identify the occluded

49
Q

correlative tests for PAD

A

CTA
MRA
arteriography

50
Q

medical treatment for PAD

A 
change risk factors
exercise
antiplatelet medication
anticoagulation
thrombolysis
51
Q

surgical treatment for PAD

A 
bypass graft
atherectomy
resection for aneurysmal disease
sympathectomy
amputation
52
Q

endovascular treatment for PAD

A

angioplasty
stent
intra-arterial directed thrombolysis

53
Q

what is an ABI

what does it specify

A
  • non-invasive physiologic test that compared systolic BP at the ankles to the systolic BP of the brachial A
  • CW waveforms are recorded to support press information

the resulting reduction in blood flow to the extremities at the ankle

54
Q

why is an ABI referred to as indirect testing

A

youre not seeing the arteries directly

55
Q

when will distal arterial flow and BP decreased significantly

A

when an arterial lumen is. narrowed to a critical level

56
Q

when should ankle BP cuffs be placed

A

2-3 cm above the medial malleolus

57
Q

which vessel in the foot is harder to compress and easier to find

A

PTA

58
Q

is the signal of the DPA is damped, retrograde or absent, how should you change your probe position

A

move to the anterior ankle area, could search for an ATA signal

59
Q

if you cant identify the DPA, which vessel do you sample instead

where is it located

A

personal artery

anterior to the lateral malleolus

60
Q

which vessel in the foot is easy to compress and harder to find

A

DPA

61
Q

do we take bilateral BRA pressures

A

YES

62
Q

if bilateral arm press is different by > 20mmHg or if the waveforms are different, where should you look

A

vertebral for SCA steal syndrome

63
Q

which brachial press do you use for the ABI calculation

A

highest

64
Q

why is it good to record the ABI for each artery in the ankle

A

if you only take the highest, you could misrepresent or miss disease

65
Q

avg ABI in supine for resting patient

normal ABI

A

1.1

> 1

66
Q

when can medial calcification of arteries cause

if ABIs are > 1.3 due to this condition, what should we do

A

falsely high ABIs

toe pressures

67
Q

in what type of patients do medial calcification occur

A

diabetics, patients on steroid medication for renal disease

68
Q

normal toe/brachial pressure

A

> 0.75

69
Q

ABI classifications

A

> 1.0 normal
0.9 - 1 minimal disease, aysmpt
0.5 - 0.9 claudication usually single level obstruction
<0.5 rest pain, severe, multilevel disease
<0.3 severe ischemia leasing to gangrene

70
Q

when we are taking an ABI, at which location are we measuring the pressure

A

the location of the cuff, not the site of doppler interrogation

71
Q

can you rely on a low pressure reading, but not a high one

A

yes

72
Q

what happens to ABIs distal pressures w/ collateralization

A

collaterals will result in normal distal pressures and waveforms at rest

73
Q

limitations of ABIs

A

bandages, trauma, surgery, ulcerations, grafts, ipsilateral side of mastectomy

74
Q

function of exercise stress testing

A

determines the functional significance of disease by evaluating the arterial hemodynamics of the lower extremities

75
Q

protocol for stress testing

A

pre-exercise BPs and ABIs
re-measure BP and ABIs w/in first minute post exercise
re-take the BPs and ABIs every 2 mins until ankle press returns to w/in 10 mmHg of the baseline press or for 6-12 mins (which ever comes first)

76
Q

findings of a normal stress test

A
  • little to no drop in ankle BP after 5 mins of exercise… < 20% change
  • decrease in post exercise BP should be < 20% of resting press and return to baseline w/in 3 mins post exercise
77
Q

diagnostic criteria for post exercise BPs and ABIs + recovery time

A

< 3 mins RT: normal
2-6 mins RT: single level disease
6-12 mins RT: multi-level disease
> 15 mins: severe occlusive disease

78
Q

what changes in ankle BPs post-exercise indicate significant arterial obstruction

A

immediate decrease from baseline in post-exercise ankle BPs

79
Q

can severity of PAD relate to the distant the patient can walk and absolute press drop

A

yes (more disease = less able to walk and greater press drop)

Vascular 2 (6 decks)

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