Peripheral Arterial Evaluation Flashcards
reasons for noninvasive arterial testing
evaluate pulsatile masses
evaluate suspected arterial trauma
evaluate angioplasty/stent placement
postoperative f/u, including bypass graft surveillance
reasons for arterial scanning
chronic atherosclersis acute occlusion aneurysm pseudoaneurysm ateriovenous fistula follow of bypass grafts
what are you looking for when scanning arterial circulation
reduction of blood flow condition of artery collateral branches changes with exercise single or multiple level disease
what is PAD
peripheral arterial disease
describe PAD
effects 8-12 million in the usa
atherosclerosis
“poor circulation”
if peripheral arterial disease isn’t treated, what might occur
worsening claudication
ley bypass surgery
leg amputation
risk factors for arterial issues
increasing age
family history
male gender
HTN **diabetes (x4 more likely) elevated cholesterol hyperlipidemia smoking atherosclerosis
treatment for arterial issues
lifestyle modification - diet changes, exercise, quit smoking
grafts, angioplasty, stent, and medication
retaining ______ extremity function is important to patients lifestyle
lower
what needs to be determined when dealing with arterial circulation issues
restriction of flow
where is the restriction
how severe is the restriction
arterial symptoms of PAD
mild - asymptomatic
moderate - claudication - asymptomatic at rest (MOST COMMON)
severe - night pain
what is claudication
CRAMPING of the leg muscles, not a severe pain
symptoms may ease after resting
adjectives used to describe claudication
cramping?
tightness?
heaviness?
tired?
cramping - fatigued
tightness - charlie horse
heaviness - sharp
tired - dull ache
PROXIMAL to the location of symptoms
thigh pain?
calf pain?
thigh pain - aortoiliac disease
calf pain - femoral or pop disease
wherever the pain is in the leg, the problem is be _______ to that pain
proximal or above
describe ischemic rest pain
pain in horizontal position (at night) relieved by standing or dangling foot in a dependent position
described peripheral pulses
describe advanced lower extremity ischemic
elevation pallor and dependent rubor
*leg up gets pale, leg down gets red
describe what happens to the tissue if there are arterial issues
tissue loss
gangrene and necrosis
insufficent blood supply ulceration
describe ischemic ulcers
painful over dorsum of the foot
gangrene - neuropathy, vasospasm
doctor will assess the leg for arterial issue by doing what
listening for a bruit
thrill - a vibration felt by palpation
decreased perpheral pulse
pulse force grading system
3+ full, bounding
2+ normal
1+ weak
0 absent
acute arterial occulsion - name the 7 P’s
pain
pallor
pulselessness
paresthesia (numbness)
paralysis (weakness)
polar (cold)
purplish
physical signs of peripheral arterial disease
elecation pallor and dependent rubor
ischemic ulcers
gangrene
bruits
decreased peripheral pulses
name the arteries of the leg
AO commonn iliac IIA and EIA CFA SFA Profunda - DFA Popliteal ATA Tibioperoneal trunk PTA Peroneal Plantar arch Dorsalis pedis
major branches of the popliteal artery
sural arteries
genicular arteries
arterial anatomy of the heart
aortic arch
1st - innominate/brachiocephalic - rt subclavian & right CCA
2nd - Lt CCA
3rd - Lt subclabvian
describe subclavian artery
right - innominate or brachiocephalic
left - aortic arch
arterial anatomy of the arm
axillary brachial radial ulnar palmar
what is the test ordered to see arteries
arteriography
describe arterial testing atmosphere
keep room temp comfortable and warm to allow for periphal dilation
supine
performed at rest
**cuff placement is key
describe the complete physiologic test - indirect/non imaging with cuffs on limbs
pulse volume recording (plethysmography) at high thigh, low thigh, below knee and ankle
segmental systolic pressures at the levels
assess on both limbs
what is PVR
pulse volume recording
changes in segmental limb volume with cardiac cycle
know pulse volume recordings for PAD and be able to tell the difference between PVR’s and CW doppler
study slide 47
_____ recordings may have a cuff artifact which produces a higher amplitude than in the thigh
calf
if amplitude of calf is equal or smaller than the thigh, ______ disease is suspected
SFA
Indirect arterial testing:
segmental pressures are obtained with the patient in the ________ position
supine
indirect arterial testing:
cuff size should be _____% larger than the limb
20
indirect arterial testing:
the legs should be at the same level as the heart because the position avoids ______ ______ artifact
hydrostatic pressure
who invented segmental pressures and when
Winsor in 1950
still remains a very sensitive indicator
how long should the rest period be before indirect arterial testing
15-20 mins
where are the blood pressure cuffs placed on the body
upper arm prox thigh low thigh calf ankle
cuff inflates to _______ mmHg above systolic pressure
20-30
what is the part of the pressure cuff that contains the air
the bladder
advantages to pressure cuff testing
simple to perform
short test time
objectibe data
instrumentation is cheaper than imaging
describe PPG photoplethysmography
for toe arteries
uses infrared light to respond to blood circulation
limitations to pressure cuff testing
casts or bandages
CHF
temperature changes
doppler angle
ischemic lesion not healing if ankle systolic pressure is below _____ mmHg
55
foot ulcers and amputation
describe direct/non imaging complete physiologic test
CW doppler of CFA, SFA, PA, ATA, PTA with correct angle (45-60)
assess on both limbs
describe ankle-brachial pressue
take the ankle pressure on the selected side and divide by the highest arm pressure (does not need to be on same side)
what is the ABI formula
brachial systolic pressure
ankle-brachial pressure index
normal >1
claudication .50-.90
rest pain .30-.50
tissue loss <.30
a pressure gradient of _____ mmHg between adjacent segments of the limb is ABNORMAL and indicates intercurrent disease
important
20
review segmental pressure examples
slide 73-77
a decrease of > ________ mmHg between two consecutive levels is considered significant and suggests obstructive disease
20-30
what is the pulsatitly index
mean velocity
______ relationship with arterial disease
inverse
no arterial disease, PI is ______
high
severe arterial disease, PI __________
decreases
CW doppler has what 3 different kinds of waveforms
triphasic
biphasic
monophasic
_______ waveform is normal artery
triphasic
_______ waveform, with increased velocity, through a mild stenosis
biphasic
______ waveform, with greatly increased velocity, through tight stenosis
monophasic
______ ______ waveform, with reduced velocity
dampened monophasic
PAD causes what…
arteries to narrow and decreases blood flow
normal vessels - _______ waveform from AO to the ankles
triphasic
characteristics of duplex imaging
red is assigned to arterial flow
color scale (PRF) adjusted - venous=low, arterial=high (sampling rate) **PRF is determined by depth**
color gain adjusted
color box adjusted
describe a normal triphasic waveform
high velocity forward flow followed by a brief flow reversal
PSV - 100 cm/s AO and decreases to 70 cm/s in popliteal artery
what does the doppler spectral waveform demonstrate
percentage of narrowing
______% diameter reduction stenosis produces what
50-99%
monophasic waveform
extensive spectral broadening
PSV of more than 100% relative to the proximal adjacent area
arteries use a _____ degree angle for consistency
60
limitations of lower extremity arterial duplex imaging
bowel gas or obesity
shadowing because of calcification
difficulty evaluating lesions
list upper extremity issues
arterial embolization from the heart thoracic outlet syndrome - impingement of the vessels - compression Raynaud's segmental pressure and PVR and CW subclavian artery stenosis with duplex
describe Raynaud’s
intermittent pallor in response to cold
cold challenge test with PPG
may be due to arterial obstruction
describe primary and secondary Raynaud
primary - NO underlying disease - transient
secondary - phenomenon - vasospasm secondary to disease
describe indirect arterial testing
brachial pressures should be obtained in both arms
difference of equal to or greater than 20 mmHg occurs between arms = arterial obstruction (usually subclavian) suspected on the side with lower systolic pressure
describe a subclavian steal
stenosis of the subclavian artery
subclavain artery steals blood from the contralateral vertebral
reversed vertebral flow
describe arterial stress testing
stressed with exercise (treadmill)
reactive hyperemia - increased pressure with cuff
mechanisms of disease…
atherosclerosis = ? embolism = ? aneurysm = ?
plaque
traveling clot
dilatation
where do aneurysms occur
AO
iliac
CFA
popliteal artery
describe pseudoaneurysms
perivascular collection neck connection results to trauma compression therapy US guided thrombin injection
describe Takayasu’s arteritis
pulseless diease
diminished pulses
non atherosclerotic
treatment – lifestyle modification, medications, surgery
review slides about grafts…
slides 126-142
