REVIEW Flashcards
vertebral artery originates where
subclavian artery
another name for palmar arch
volar arch
superficial palmar/volar arch includes what
branch of radial artery
distal portion of ulnar artery
deep palmar/volar arch includes what
branch of ulnar artery
distal portion of radial artery
the dorsalis pedis artery is formed from
the anterior tibial artery
major branch of dorsalis pedis artery
deep plantar artery
the deep plantar artery joins with what
lateral plantar artery (branch of posterior tibial artery)
what vessels make up the plantar arch
deep plantar artery (branch of dorsalis pedis)
lateral plantar artery (branch of posterior tibial)
the adventicial/externa layer of arteries contains what
vaso vasorum
hydrostatic pressure is also referred to as
gravitational energy
resistance equation
R = 8nL / r4pie
resistance is directly proportional to
viscosity and length
resistance is inversely proportional to
radius of vessel
what has the most dramatic effect on resistance?
change in vessel diameter
what type of energy loss is evident at exit of stenosis
inertial
poiseuille’s equation defines relationship between
pressure
volume
resistance
poiseuille’s equation
Q = P/R
pressure and resistance
Poiseuille’s equation as a whole
Q = (p1 - P2) pie r4 / 8nl
law of conservation of mass
Q = A x V
area and velocity
bernoulli describes
relationship between velocity and pressure
in a flow seperation velocity _____ and pressure _____
velocity decreases
pressure increases
low resistance vessels
ICA celiac renal splenic hepatic vertebral
high resistance vessels
eca
fasting sma
extremity arteries
flow proximal to a significant stenosis
higher resistance
monophasic waveform
dampened (little or no diastole)
at a stenosis
elevated velocity
spectral broadening
increased doppler shift frequencies
post stenosis doppler
lower resistance
rounded in appearance
spectral broadening
flow reversal in high resistance vessels may disappear distal to a stenosis because of
decreased peripheral resistance
due to ischemia
vasodilation does what
lowers distal peripheral resistance
increases blood flow
exercise decreases what
resistance
waveform seen in an extremity after exercise
low resistance
monophasic
due to vasodilation
cross sectional area reduction of 75% = _____ diameter reduction
50%
a monophasic waveform is often obtained where
proximal to an obstruction
analog doppler is not capable of portraying velocities of less than
6cm/sec
spectral analysis
individual frequencies are displayed using fast fourier transform method FFT
pulsatility index
dividing peak to peak frequency difference (P1 - P2) by mean (average) frequency
accerelation time is measured because
if theres a proximal obstruction there is a slowing of the time between the onset of systole to the point of maximum peak
acceleration time that indicates proximal iliac disease
> 133m/sec
uncompensated CHF can
dampen waveforms
give decreased ABIs
width of segmental pressure cuffs should be
20% greater than diameter of limb
cuff should be inflated
20-30mmHG past last audible arterial signal
OR
inflated 20-30mmHg above highest brachial
systolic pressure is recorded as
the pressure at which the first audible arterial signal returns
ABI is calculated by
ankle pressure / highest brachial pressure
order of segmental pressures
brachial
ankle (PTA/DPA)
calf (PTA/DPA)
thigh (PTA OR POP)
normal extremity ABI
> 1.0
likely normal extremity ABI
.9-1.0
mild arterial disease extremity ABI
.8 - .9
moderate arterial disease extremity ABI
.5-.8
CLAUDICATION
Severe arterial disease extremity ABI
ABI is unreliable / incompressible vessel
> 1.3-1.5
segmental pressure drop between levels indicates a significant obstruction
30 mmHG
a horizontal difference in pressures indicates a significant obstruction
20-30mmHg
suggest disease at or above extremity with lower pressure
four cuff technique thigh high pressure should be
around 30mmHg more than highest brachial pressure
four cuff technique at knee and below pressure should be
around the same as highest brachial pressure
three cuff technique high thigh pressure should be
around the same as highest brachial pressure
toe pressures for ulcers that fail to heal
<30mmHg
post exercise dopplers should be obtained
effected side first
both ankles
highest brachial
normal post exercise ABI does what
increases
abnormal post exercise ABI does what
decreases
ABI post exercise single level disease recovery
takes 2-6 minutes for ABIs to increase back to resting levels after exercise
multilevel disease recovery
takes 6-12 minutes for ABIs to increase back to resting levels after exercise
reactive hyperemia techinque
19x40cm thigh cuffs inflated bilaterally 20-30mmHG above highest brachial for 3-5 minutes
normal limb ABI after reactive hyperemia
decrease of 17-34%
single level disease ABI after reactive hyperemia
< or = decrease of 50% in ankle pressure
multiple level disease ABI after reactive hyperemia
> 50% ankle pressure drop
cuff sizes for upper extremity seg pressures
12 x 40cm upper arms
10 x 40 cm forearms
50% stenosis of subclavian artery OR vessel under cuff of UE segmental pressures is indicated by a pressure drop of what
15-20mmHg from one brachial to another
what information do you need to get for penile imaging
doppler CFA, PTA, DPA,
obtain ABIs
penile pressure with doppler or PPG
penile imaging cuff size
2.5 x 12cm
normal penile brachial index
> or = .75
marginal penile brachial index
.65-.74
abnormal penile brachial index
penile doppler normal results
cavernous arteries size increase post injection
PSV increases 30cm/sec higher
dorsal vein should not increase
dorsal vein doppler
< 3 cm/sec normal
>20cm/sec abnormal
plethysmography is used to
determine true claudication vs nonvascular sources
localize area of obstruction
PPG is mainly used for
digits and penile exams
volume air plethsmography cuffs are inflated to
10-65mmHg
how does volume air plethsmography work
pressure xducer converts pressure changes into analog waveforms and displays them on strip chart recorder
PPG detects
cutaneous blood flow
cuteaneous blood flow in PPG determines
the amount of reflection
increased blood flow in PPG results in
increased attenuation
decreased reflection
positive upstroke
volume air plethysmography start at
upper extremity and move distally
PPG results: normal
rapid upstroke
sharp systolic peak
reflective wave
PPG results: minimally abnormal
rapid upstroke
sharp peak
no reflective wave
downslope bowed away from baseline
PPG results moderately abnormal
slow up stroke and down stroke
flattened systolic peak
no reflective wave
PPG results severely abnormal
low amplitude or absent
reduced amplitude with normal wave reflects
insignificant disease unless its unilateral
good waveform with abnormal segmental pressures reflects
collaterals
displacement plethysmography: displacement is measured by
amount of displacement of water in chimney
displacement plethysmography: volume change is measured by
spirometer
with volume air plethysmography if cuff is too tight
can obliterate or diminish wave forms
toe plethysmography exam cuff size
1.2 times size of toe
about 2.5-3cm cuff applied to base of great toe
PPG toes method
cuff at base of great toe
photocell attached to plantar side of toe
paper speed slowed to 5mm/sec
cuff inflated to 20-30mmHg past highest brachial pressure
no pulsations are seen
cuff slowly deflated until first pulse returns
PPG fingers without cold stress
UE arterial study Pressures doppler palmar arch to verify patency apply finger cuffs (2-2.5cm) same method as toes
PPG fingers with cold stress
after resting study hands go into cold water for 3 minutes
then waveform and pressures obtained immediately and then after 5 minutes
normal PPG digital waveform qualities
sharp upstroke
downstroke with reflected wave/notch halfway down
finger amplitude greater than toes
abnormal obstructive PPG digital waveform
slow upslope
rounded peak
downslope bows away from baseline
digital abnormal peaked waveform
slow upslope
sharp anacrotic notch
reflected wave high on downslope
Raynauds disease waveform
peaked pulse
digital PPG completely abnormal if
waveforms fail to return after 5 minutes
UE digits Finger/brachial index
.8-.9
LE digits toe/brachial index
60-80% of brachial pressure
Transcutaenous Oximetry is used to determine
if ulcers will heal
amputation level
TCP02 technique
clean skin with alcohol pad
ring fixed on skin
electrolyte solution put inside ring
electrode attached to ring
TcP02
heats skin to 45 celcius blood flow increases, lipid layer melts 02 escapes through skin measured by sensor in electrode electrode converts chemical reaction to reading of 02 converted into mmHg
TcP02 calibration
manual
healing likely to occur
70-80mmHg
borderline healing
30-40mmHg
non healing
10-15mmHg
sample size for acquiring pulsed doppler information
1-1.5mm
most common sites of stenosis of hemodialysis graft site is
venous anast and outflow
steal syndrome of hemodialysis graft site is caused by
distal arterial flow reversed into venous circulation
assess for steal of graft site
ppg on atleast two fingers
manual compression of graft
if flow to digits improves —> steal
if flow does not improve –> no steal
if the patient has steal syndrome what are the symtoms
pale hand
coolness of skin dst to shunt
pain in fingers and hand
doppler equation
df = 2FoVCos0 /C
df = doppler shift FO = transducer frequency V= velocity of moving reflectors c= speed of sound
speed of sound through soft tissue
1540 m/sec
calculating velocity equation
V = c DF/ 2FO cos 0
Reversed Saph Vein Graft RSVG
small end prox
large end distal
vein valves stay open due to arterial flow pressure
branches are ligated
in situ vein graft
stays in place
valves broken up prior to surgery
branches ligated
synthetic bypass graft
gortex
bypass graft imaging
ABIs inflow art prx art anast body dst art anast outflow art vein graft check for branches may lead to av fistula
stenotic PSV to pre stenotic PSV 2:1 ratio
50% diamater reduction
stenotic PSV to pre stenotic PSV 4:1 ratio
75% diameter reduction
PSV >400cm/sec
75% diameter reduction
normal bypass graft doppler
lower resistance
retrograde flow seen in native artery at distal anastomosis of RSVG
abnormal bypass graft doppler
decrease of 30 cm/sec
change in waveforms
decrease of ABI >.15
RAR equation
highest renal artery PSV / aorta PSV
normal RAR
<3.5
you cannot use RAR if
AAA
Ao PSV >90cm/sec or less than 40cm/sec
abnormal RAR
> 3.5 suggest 60% diameter reduction
End diastolic ratio (EDR) or PR
EDV / PSV
normal EDR or PR
> .2
abnormal EDR or PR
Resitive index (RI) equation
PSV - EDV / PSV
normal RI for kidneys
Acceleration time of what is considered to be abnormal for kidneys
> 100cm/sec
fasting SMA
high PSV
low EDV
flow reversal
non fasting SMA
PSV and EDV increased
loss of flow reversal
normal SMA PSV
110-177cm/sec
stenosis of SMA
> 275cm/sec
70% diameter reduction
celiac artery fasting
high PSV and EDV
no flow reversal
celiac artery non fasting
no change
celiac artery normal velocity
50-160 cm/sec
stenosis of celiac artery
> 200cm/sec
70% diameter reduction
celiac band syndrome
compression of celiac artery by median arcuate ligament of diaphgram
what do you see with celiac band syndrome
stenosis on expiration
improved with deep inspiration
waveform seen proximal to an AV fistula
increased diastolic flow because fistula reduces resistance
flow throughout fistula
high velocity
low resistance
epigastric artery
branch of internal mammary artery
what supplies rectus abdominus
epigastric artery and perforators
internal mammary artery is also known as
internal thoracic artery
internal mammary/internal thoracic artery arises off of
subclavian artery
vein dimension for vein mapping
at least 2-3mm
outter to outter
most common compression of thoracic outlet syndrome is
brachial plexus (97%)
ICA branches
opthalmic artery
posterior communicating artery
ICA terminates in the
middle cerebral artery
anterior cerebral artery
first branch off of ECA
superior thryoid artery
basiliar artery divides into
posterior cerebral artery
circle of willis includes
dst ica ant cerebral artery ant communicating artery post cerebral art post communicating art
supraorbital artery is a brach off the
ophthalmic artery
supraorbital artery joins with
ECA via superficial temporal artery
frontal artery
arises from ophthalmic art
supplies mid forehead
joins eca
ECA ICA anastomosis
via orbital and ophthalmic artery
occipital branch of ECA anasts with
atlantic branch of vertebral art
poiseuill’s law and resistance equation
Q = (P) pie r4 /8nL p= pressure r= radius of vessel n = viscosity l= length
atheromatous plaque is formed
within or beneath intima
fatty streak
thin layer or lipid material on intimal layer
fibrous plaque
lipids
collagen
elastic fibers
homogenous
complicated plaque
fibrous plaque that includes collagen calcium cellular debris echogenic and heterogenous
ulcerative lesion plaque
smooth surface of fibrous cap deteriorates
can result in distal embolism
intra-plaque hemorrage
evident as sonolucent area within plaque
fibromuscular dysplasia is
dyplasia of media and overgrowth of collagen in mid/dst ica
FMD is common in
young women
neointimal hyperplasia
intimal thickening from rapid production of smooth muscle cells
common post endarterectomy
lt cva results in
problems on right side of body
eye symptoms suggest disease of
ICA on the same side
ICA disease symptoms
unilateral paresis (weakness) unilat paresthesia (pins and needles) aphasia (difficulty speaking) amaurosis fugax (blindness of one eye)
MCA disease symptoms
aphasia, dysphasia
facial and arm paralysis
behavorial changes
ACA disease symptoms
severe hemiparesis or plegia
incontinence
loss of coordination
vertebrobasilar disease symptoms
vertigo diplopia ataxia (loss of coordination) drop attack bilat parethesia
PCA disease symptoms
dyslexia
coma
carotid doppler uses
spectral analysis
continuous wave doppler
pulse doppler
continuous wave
2 crystals one constantly sending one receiving
no range resolution
fixed sample size
pulsed wave doppler
crystals send then receive
high range resolution
variable sample size
high resistance patterns of ICA consider disease
carotid siphon
normal PSV of carotids
<125 cm/sec
carotid PSV with less than 50% stenosis
PSV <125cm/sec
carotid PSV/EDV with 50-75% stenosis
PSV >125cm/sec
EDV <140 cm/sec
carotid PSV/EDV with 80-99% stenosis
PSV >125cm/sec
EDV >140cm/sec
NASCET criteria for carotids > than 70% stenosis
ICA/CCA ratio >4.0
occlusion signals of carotids
CCA may have low or absent diastole
pre occlusive thump
maximum frequency is
1/2PRF
nyquist limit
flow greater than 1/2 PRF
to increase PRF or nyquist limit
change scale change transducer frequency bring down baseline change wall filter use CW doppler change depth change angle of insonation
mirror image/cross talk
doppler shifts above and below baseline
artifact from strong reflectors or too much gain
transtemporal approach for
MCA
ACA
PCA
dst ICA
transorbital approach for
ophthalmic and carotid siphon
transforaminal/suboccipital approach
vert and basilar art
MCA
30-60mm
antegrade
55 +/- 12cm/sec
angle: ant/sup
ICA
55-65mm
bidirectional
55 +/-12 cm/sec
ant/sup
ACA
60-80mm
retrograde
50 +/-11cm/sec
ant/sup
PCA
60-70mm
antegrade
39 +/- 10cm/sec
posterior
Opthalmic artery
40-60mm
antegrade
21 +/1 5
medial
ICA carotid siphon
60-80mm supraclinioid : retrograde genu: bidirectional parasellar: antegrade 47 +/-14 cm/sec
Vertbral artery
60-90mm
retrograde
58 +/- 10cm/sec
right/lt of midline
basilar artery
80-120mm
retrograde
41 +/- 10 cmsec
midline
cross over of ACA
antegrade flow in ACA due to cross over collateralization
external to internal collateralization
retrograde flow in ophthalmic artery
posterior to anterior collateral pathway
increase flow in PCA
reversed flow in pcom artery
occlusion is most accurately identified in
ICA or MCA
vasospasm most accurately identified in
MCA
vasospasm
> 120cm/sec
severe vasospasm
> 200cm/sec
AV malformation causes
increased systolic and diastolic flow
low PI
reduced flow in adjacent arteries
subclavian steel results in
retrograde flow in ipsilateral vertebral artery
calculate diameter reduction
1 - d/D x 100
may thurners syndrome
lt common iliac vein travels under rt common iliac artery and may be compressed leading to DVT in left lower extremity
intracranial venous sinus
space between dura matter and periosteum that drains blood into jug vein
veins without valves
IVC SVC innominate iliac soleal sinuses
GSV # of valves
12 mostly below knee
small saph v # of valves
6-12
perforators # of valves
each contain a valve
infra pop veins # of valves
7-12
pop and fem vein # of valves
1-3 each
common fem v # of valves
1
IJV # of valves
1
shape of veins is determined by
transmural pressure
pressure within vein vs pressure outside of vien
low transmural pressure
low blood volume
hour glass shaped vein
(offers more resistance)
high transmural pressure
high blood volume
circular shaped
hydrostatic pressure equation
HP = PGH P= specific gravity of blood G= acceleration due to gravity H= distance from the heart
what helps propel blood towards the heart
muscle contraction
ineffective calf pump muscle results in
reflux
venous volume and pressure increases
venous pooling
ambulatory venous hypertension
inspiration
decrease in intrathoracic pressure
increase intra abdominal pressure
decrease venous return from legs
increase venous return from arms
expiration
increase intra thoracic pressure
decrease intra abdominal pressure
increase venous return from legs
decrease venous return from arms
valsalva
increases intra thoracic and intra abdominal pressure
all venous flow should halt
same as prx compression during lower extrem exam
phlegmasia alba dolens
arterial spasm due to iliofemoral thrombosis
causes pallor
phlegmasia cerulea dolens
severely reduced venous outflow from iliofemoral thrombosis
causes cyanosis
pitting edema causes
fluid retention
CHF
elevated venous pressure
virchows triad
venous stasis
hypercoagulability
trauma to vessel
picc line will most likely develop thrombosis
proximal picc
paget schroetter syndrome
stress induced dvt of axillary or subclavian vein
common in young men
venous form of TOS
superior vena cava syndrome
obstruction by neoplasm
pt may have cough/sob
with SVC syndrome what happens to flow
flow in UE remains the same during inspiration
primary varicose veins
dilated superficial veins due to incompetence of superficial system
deep system intact
secondary varicose veins
dilated superficial veins due to incompetence of superficial system that is caused by DVT
deep system not intact
klippel-trenaunay
multiple varicosities of superficial system
hypoplastic or absent deep veins
chronic venous insufficiency
stretching of walls results in damage to valves
increase venous pressure causes flow changes
post phlebitic syndrome
chronic flow changes result in persistent edema, stasis, pain
may lead to ulceration
PPG venous normal venous refill time VRT
> or = 20 seconds
PPG venous superficial system incompetence VRT
<20 sec without tourniquet
then normalizes to >20 seconds with tourniquet
PPG venous deep system incompetence VRT
< 20 seconds with and without tourniquet
PPG of venous system is used to detect
venous insufficiency
venous reflux
venous APG cuff inflates to
6mmHg
venous filling index shows what
rate of venous refilling
VFI is calculated using
Venous Volume (VV) Venous filling time (VFT)
normal VFI should be
low number
what measures the calf muscle pump function
Ejection Fraction EF
EF is calculated how
Ejection volume (EJ) Venous Volume (VV)
normal EF is
high percentage
the calf expels how much of venous blood volume with one toe pump
60%
Residual volume fraction RVF is equivalent to
ambulatory venous pressure in mmHg
Residual volume fraction is calculated how
percentage of VV remaining after 10 toe tips
RVF should be
low %
limitations of APG
will not diagnose incompetent perforators or isolated incompetent distal veins
APG systems are
manually calibrated
VV is calculated
EV and VRT
sources of false positives for CW venous doppler
extrinsic compression
peripheral arterial disease PAD
COPD
PAD can cause
decreased venous filling
COPD can cause
elevated central venous pressure
trendelenburg position for venous doppler
head 30 degrees lower than heart
venous flow patterns
spontaneous
phasic
augment with dst compression
aug with prx release
to improve venous doppler imaging
adjust scale
change wall filters
increase gains
with chronic venous insufficiency what do you normally see with valsalva
flow reversal which indicates reflux
venous insufficiency testing with doppler cuffs sizes
19x40 thigh
12 x 40 calf
12x40 ankle
rapid cuff inflator for venous insufficiency inflates
80 mmHg thigh
100 mmHg calf
120 mmHg foot
spectral analysis with chronic venous insufficiency
reversed flow lasting more than 30 seconds to 1 minute
color flow with chronic venous insufficiency
color change noted during prx compression or cuff deflation
if flow is not spontaneous at CFV FV and POP veins
obstruction distal to or at that site
if flow is continuous and not phasic
prx obstruction
no augment is dst compression is seen
obstruction between where you are compressing and where you are listening
if flow increases during prx compression
venous reflux
rouleau formation
slow swirling flow seen within vein
could suggest prx obstruction
doppler seen with chronic venous thrombosis
venous reflux lasting 30 sec or longer
continous or decreases phasicity
