URR Upper Extrem Arterial Anatomy and Eval Flashcards
first branches of the ascending AO?
right and left coronary As
three branches of the Ao arch?
-innominate (branches into Rt CCA and Rt subclavian, NO left innominate A)
-lt CCA
-lt subclavian
the aortic arch rises from where and arches where?
arises right side of heart and arches towards the left to course inferior to through the chest and abdomen
-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
bovine arch
complications of the double aortic arch
compresses anterior aspect of the trachea and the posterior aspect of the esophagus
complications of pulmonary sling?
compresses anterior aspect of the trachea and posterior aspect of the esophagus
complication of lt aortic arch with aberrant rt subclavian A
compression of esophagus
complications of rt aortic arch with aberrant lt subclavian
compression of esophagus
-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
innominate artery
what is the aberrant rt subclavian?
-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
where does the lt subclavian course?
-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
what are the branches from the subclavian?
-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)
flow in the subclavian?
-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
branches of the axillary Artery?
-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)
where is the brachial A located?
from distal axilla to antecubital fossa
-divides into radial and ulnar arteries just prox to the antecubital fossa
where is the radial artery?
-courses laterally on the forearm
-branch joins the superficial palmar arch
-terminates at the deep palmar arch
where is the ulnar artery
-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
where are the digital arteries?
-originate from both palmar arches
-distribute blood to the fingers
physical exam steps?
-palpation
-auscultation
-eval color of the extrem when elevated and dependent
-assess the skin and nails
-test capillary blush response
why do auscultation?
-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)
atherosclerotic disease in the uppper extrems is very
uncommon
where to do duplex eval in the upper extrem?
-subclavian
-axillary
-brachial
-radial
-ulnar
how to do segmental pressures of upper extrem?
-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
what syndromes can all lead to reduced digital pressures?
raynaud, atherosclerosis, buerger disease, and thoracic outlet syndrome
what is an abnormal finger/brachial index?
< .8
reduced single digit pressure with normal arm and wrist pressures indicates disease where?
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
reduction in pressure of all the digits indicates disease in where?
radial and ulnar arteries of the palmar arch
reduced pressure in the digits of one side of the hand indicates what?
palmar arch disease
what is PVR of the upper extrem used for?
-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
what is photoplethysmoraphy (PPG)?
-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
what is the allen test?
-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
how to do allen test?
-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
what is cold sensisitivity testing?
-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
what is radial artery mapping?
-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
why is the radial A preferred over GSV for coronary bypass graft?
-lumen size is suitable for procedure
-thicker wall layers
-easier to access for harvesting
contraindications for radial artery mapping?
stenosis or occlusion of the radial A and/or other arteries in the extrem, digital ischemia, incomplete palmar arch, and raynaud syndrome
what is the protocol for radial A mapping?
-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
