URR Upper Extrem Arterial Anatomy and Eval

Question 1

first branches of the ascending AO?

Answer 1

right and left coronary As

Question 2

three branches of the Ao arch?

Answer 2

-innominate (branches into Rt CCA and Rt subclavian, NO left innominate A)
-lt CCA
-lt subclavian

Question 3

the aortic arch rises from where and arches where?

Answer 3

arises right side of heart and arches towards the left to course inferior to through the chest and abdomen

Question 4

-most common anatomic variant of the arch
-only two direct branches of the arch
-the innominate and the left CCA originate as one short segment and then split
-second branch is the lt subclavian A

Answer 4

bovine arch

Question 5

complications of the double aortic arch

Answer 5

compresses anterior aspect of the trachea and the posterior aspect of the esophagus

Question 6

complications of pulmonary sling?

Answer 6

compresses anterior aspect of the trachea and posterior aspect of the esophagus

Question 7

complication of lt aortic arch with aberrant rt subclavian A

Answer 7

compression of esophagus

Question 8

complications of rt aortic arch with aberrant lt subclavian

Answer 8

compression of esophagus

Question 9

-first major branch from the arch
-also called brachiocephalic A or trunk
-only one artery, may be called the right but there is no left
-courses upwards and rightward, anterior to trachea
-bifurcates posterior to the right sternoclavicular joint
-right CCA and rt subclavian As are the only two branches

Answer 9

innominate artery

Question 10

what is the aberrant rt subclavian?

Answer 10

-in some patients the subclavian A can be a direct branch of the Ao distal to the lt subclavian origin
-called retroesophageal subclavian A or aberrant subclavian A
-usually originates from dilated segment of the prox descending Ao called the kommerell diverticulum
-can cause dysphagia due to compression of the esophagus by the aberrant subclav A
-also related to ortner syndrome - palsy of the recurrent laryngeal nerve

Question 11

where does the lt subclavian course?

Answer 11

-posterior to the anterior scalene muscle and clavicle
-courses anterior to the apex of the lung
-becomes the axillary a at the level of the first rib

Question 12

what are the branches from the subclavian?

Answer 12

-vertebral A
-internal mammary A (AKA internal thoracic artery)
-thyrocervical and costocervical trunks (can be differentiated from the vertebral As by their many branches and lower end diastolic flow velocities)

Question 13

flow in the subclavian?

Answer 13

-triphasic waveform, high resistance
-flow velocity varies
-compare velocities in both subclavian As; high PSV can indicate stenosis in that A
-biphasic or monophasic flow patterns associated with obstruction

Question 14

branches of the axillary Artery?

Answer 14

-superior artery
-thoracic artery
-thoracoacromial A
-lateral thoracic artery
-subscapular A
-anterior and posterior humeral A
-thoracodorsal A
(axillary becomes axillary A just outside A)

Question 15

where is the brachial A located?

Answer 15

from distal axilla to antecubital fossa
-divides into radial and ulnar arteries just prox to the antecubital fossa

Question 16

where is the radial artery?

Answer 16

-courses laterally on the forearm
-branch joins the superficial palmar arch
-terminates at the deep palmar arch

Question 17

where is the ulnar artery

Answer 17

-courses medially on the forearm
-branch joins the deep palmar arch
-terminates at the superficial palmar arch
-supplies majority of the blood to the hand

Question 18

where are the digital arteries?

Answer 18

-originate from both palmar arches
-distribute blood to the fingers

Question 19

physical exam steps?

Answer 19

-palpation
-auscultation
-eval color of the extrem when elevated and dependent
-assess the skin and nails
-test capillary blush response

Question 20

why do auscultation?

Answer 20

-commonly used to assess hemodialysis grafts
-a graft stenosis can cause a bruit
-a pseudoaneurysm will also cause a bruit
-water hammer pulse (associated with an occluded graft)

Question 21

atherosclerotic disease in the uppper extrems is very

Answer 21

uncommon

Question 22

where to do duplex eval in the upper extrem?

Answer 22

-subclavian
-axillary
-brachial
-radial
-ulnar

Question 23

how to do segmental pressures of upper extrem?

Answer 23

-cuffs placed snugly on upper arm, forearm, and second digit
-inflate the cuff to 20-30 mmHg above the last audible signal
-use brachial to obtain the brachial pressure
-use the radial to obtain radial pressures in forearm
-use ulnar to obtain ulnar pressures
-finger pressures should be obtained with the patient sitting upright
-if pressure measurements should be repeated, cuff should be fully deflated for at least one minute before reinflating
-record and compare pressure measurements
-calculate wrist/brachial index using highest wrist pressure divided b the highest brachial pressure

Question 24

what syndromes can all lead to reduced digital pressures?

Answer 24

raynaud, atherosclerosis, buerger disease, and thoracic outlet syndrome

Question 25

what is an abnormal finger/brachial index?

Answer 25

< .8

Question 26

reduced single digit pressure with normal arm and wrist pressures indicates disease where?

Answer 26

palmar arch or the digital artery with the lower pressure -could be disease in the palmar arch or single digit -to provide a complete eval, at least one more digit on the left hand should be evaled -if additional digit pressure is abnormal, disease in the palmar arch is the most likely cause for reduced pressures -if additional digit pressure is normal, remaining digits should be tested to confirm that it is limited to the single digit and disease of that digital artery should be suspected

Question 27

reduction in pressure of all the digits indicates disease in where?

Answer 27

radial and ulnar arteries of the palmar arch

Question 28

reduced pressure in the digits of one side of the hand indicates what?

Answer 28

palmar arch disease

Question 29

what is PVR of the upper extrem used for?

Answer 29

-most commonly used to assess the upper extrem for thoracic outlet syndrome -finger tracings should be obtained with patient sitting upright -abnorm PVR tracings w/ stenosis or TOS - prolonged stroke, rounded peak, loss of dicrotic notch, delayed downslope

Question 30

what is photoplethysmoraphy (PPG)?

Answer 30

-sensors used to assess the upper extrem for thoracic outlet syndrome and raynaud syndrome -abnorm PPG tracings w/ stenosis or TOS - prolonged upstroke, rounded peak, loss of dicrotic notch, delayed downslope -flatline tracing with occlusion with no collateral pathways -raynaud syndrome will produce a tracing with a double peak with stimulation

Question 31

what is the allen test?

Answer 31

-used to eval patency of the palmar arch for arterial harvesting of the radial A -abnorm results can indicate arterial obstruction of the palmar arch or an incomplete arch

Question 32

how to do allen test?

Answer 32

-radial A compressed while fist clenched to induce pallor and then while maintaining radial compression the fist is relaxed to see if color returns (normal) -if pallor remains, ulnar A is not patent and the radial A cannot be harvested w/o causing damage to the hand circulation -PPG sensors can be placed on the thumb or index finger to monitor flow changes during arterial compression -radial compression should not cause changes in tracings if ulnar is patent -if ulnar diseased, waveform amplitude will diminish or flatline -digital cuffs could be used to assess pressure changes with radial compression -radial compression should not cause any changes if ulnar is patent -if ulnar diseased, pressures will diminish significantly

Question 33

what is cold sensisitivity testing?

Answer 33

-used to assess patients with symptoms related to exposure to cold temps -PPG tracings obtained from digits before and after immersion in ice water for up to 3 mins -document patient signs and symptoms after stimuli used -obtain tracings just after immersion and after 5 mins -immediately after immersion the amplitude of the waveform will decrease -abnorm if the amplitude of the waveform does not return to normal in 5 mins

Question 34

what is radial artery mapping?

Answer 34

-radial A can be used for coronary bypass procedure -usually harvested from non-dominant arm -diameter over 2 mm can be used, but >2.5 mm is preferred

Question 35

why is the radial A preferred over GSV for coronary bypass graft?

Answer 35

-lumen size is suitable for procedure -thicker wall layers -easier to access for harvesting

Question 36

contraindications for radial artery mapping?

Answer 36

stenosis or occlusion of the radial A and/or other arteries in the extrem, digital ischemia, incomplete palmar arch, and raynaud syndrome

Question 37

what is the protocol for radial A mapping?

Answer 37

-eval for stenosis -measured inner diameter of the prox, mid and distal radial A -note the position of the brachial A bif related to the antecubital fossa