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ESP Vascular > Vascular > Flashcards

Vascular Flashcards

1
Q

13 µs rule

A

Propagation velocity equals time

The signal obtained at 13 µs is from 1 cm deep

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2
Q

Doppler angle of insulation for vascular applications is

A

60° or less

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3
Q

Two types of continuous wave Doppler

A

Analog/think average

Digital/detail 

FFT analyzes and displays all the frequencies moving through sample area

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4
Q

PW Doppler

A

The primary technique used in duplex scanning

Pulse Doppler has range or depth resolution

May alias if the Doppler shift at frequency is greater than 1/2 the PRF/Nyquist limit

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5
Q

Sample volume size for most arterial applications

A

1.5 to 2.5 mm.

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6
Q

Arterial system anatomy

A

Arteries/transport, gases, nutrients, and other essential substances to the capillaries.

Arteriolae’s /resistance vessels, assist with regulating blood flow through contraction and relaxation

Capillaries/nutrients and waste products are exchanged between the blood and tissue

Venules/collect blood from the capillary beds

Veins/collect blood from the venules and return it to the heart

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7
Q

Anatomy of a vessel walls

A

Tunica intima/innermost layer

Tunica media/metal and thickest layer

Tunica adventitia, externa/the outer most layer contains fibrous, connective, tissue and muscle fibers. Also contains the vasa vasorum ( the blood supply within the blood supply )

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8
Q

Aorta

A

Aortic arch/3 main branches

Ascending aorta/from the aortic valve to the first branch

Descending thoracic aorta/from the arch to the diaphragm

Abdominal aorta/begins as the aorta passes through the diaphragm and terminates at the aortic bifurcation into the iliac arteries 

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9
Q

Branches of the aortic arch

See diagram

A

Brachiocephalic trunk (innominate) artery/1st and largest branch off of the aorta, begins directly after aortic arch. Bifurcates into right subclavian, and right common carotid arteries.

Left common carotid artery/2nd branch directly off of the aortic arch

Left subclavian artery/3rd branch off aortic arch

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10
Q

Upper extremity arteries

See diagram

A

Subclavian artery/terminates into axilla artery at the first rib

Axillary artery/passes behind clavicle and terminates into the brachial artery at the axilla

Brachial artery/main blood supply to the arm, divides into radial and ulnar

Radial artery/lateral, thumb side, terminates in deep palmar arch

Ulnar artery/medial, pinky side, terminates into superficial palmar arch

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11
Q

Abdominal aorta and visceral branches

See diagram

A

Celiac artery/supply, stomach, liver, pancreas, duodenum, spleen. Divides into left gastric artery, common hepatic artery, and splenic artery
* left gastric artery supplies, stomach, esophagus. Common hepatic artery supplies, liver. Splenic artery, supplies, spleen.

Superior mesenteric artery (SMA)/ supplies, the small intestine, cecum, parts of colon.
* SMA, and celiac may have a common trunk

Renal arteries/ just below SMA, supplies, kidneys, suprarenal gland’s, ureters. And transverse, the left renal vein is a landmark for identifying renal arteries.

Inferior mesenteric artery/supplies, transverse and descending colon, rectum

To potential collateral connections between the SMA and IMA /
Marginal artery of the colon (a.k.a. the marginal artery of drummond) and arc of Riolan

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12
Q

Aortic bifurcation

A

Common iliac arteries/supply the pelvis, abdominal wall, lower limbs

Divides into the :

Internal iliac artery/hypogastric artery, supplies, pelvis, and inner thigh

External iliac artery/supplies the leg
Terminates into the common femoral artery. **Landmark- Psoas Major muscle

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13
Q

Lower extremity arteries

See diagram

A

CFA / EIA Becomes the CFA at the inguinal ligament

SFA/medial thigh, becomes the pop artery

DFA/supplies thigh, collateral pathway via connections to the pop artery (genicular branches)

Pop artery/continuation of the SFA as it passes through the adductor hiatus where there is an opening and two adductor Magnus muscle. Genicular branches connect with the profunda branches. Terminates into the trifurcation.

ATA/the first branch of the distal pop artery, terminates into the DPA

Tibial/peroneal trunk/branches into PTA and peroneal artery

PTA/medial side of leg, branches are plantar arteries, supplies foot

Peroneal/fibula side, supplies, leg, and foot

Plantar arch/digital arteries/ I DPA, and PTA form the plantar arch

Are plantar and dorsal metatarsal arteries, arise from the plantar arch and supply the digits

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14
Q

Atherosclerosis obliterans (ASO)

A

The most common arterial pathology

Thickening and hardening of plaque within the arterial wall between the intimal and medial

Claudication, exertional, leg pain, is the most common symptom and PAD

Ischemia and possible amputation is most feared consequence

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15
Q

Arterial occlusion

A

Thrombosis/progression of disease until the stenosis thrombosis and includes completely.

Embolus/obstruction of a vessel, by foreign substance, most frequent, thrombus or plaque.

6 P’s associated with a Q arterial occlusion
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikiloderma/ Polar

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16
Q

Aneurysm

A

Dilated artery greater than 1 1/2 times the diameter of the adjacent artery ** 50% increase in diameter

Dilatation of the artery involving all three layers of the arterial wall (intima, media, adventitia)

Classified by morphology
-Fusiform/spindle-shaped
-saccular/sac off vessel

Most common location is infrarenal, abdominal aorta

Patience with an aneurysm, have a much higher incidence of another

50% of patients with pop artery aneurysm will have an aortic aneurysm

Most frequent complications :
AAA-rupture
Peripheral artery aneurysm (leg/arm)-embolization

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17
Q

Arterial dissection

A

Intimal wall layer develops a tear and filled with blood, dividing the vessel into a true lumen, and a false lumen

Active flow in both lumens

Most often occurs in thoracic aorta

Cause/spontaneous, trauma, hypertension

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18
Q

Coarctation of the aorta

Say diagram

A

*narrowing

Congenital anomaly

Involves thoracic aorta

Symptoms include leg, pain, absent, pulses, hypertension, due to decreased renal perfusion

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19
Q

Fibromuscular dysplasia
(FMD)

A

Non-atherosclerotic disease, that results in abnormal cellular growth in the walls of the medium and large arteries affecting the medial layer of the vessel

Rare disease, primarily found in middle, aged women

Commonly seen in the distal ICA and renal arteries

Beading of the vessel lumen
“ string of pearls”

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20
Q

Arteritis

A

Inflammation of the arterial wall
More common in small vessels, digital arteries, tibial vessels

Three types :

-Buerger’s disease/occurs primarily in men less than 40 and heavy smokers. Often present with occlusion of the distal arteries and rest pain/ulceration.

-Takayasu’s arteritis/affects the aortic arch and its branches. Most common in females referred to as pulselessness disease.

-Temporal arteritis/affects temporal artery. Untreated may lead to blindness.


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21
Q

Vasospastic disorders

A

Raynauds phenomenon/digital ischemia due to small vessel, vasospasm secondary to cold, exposure or stress.
-Primary raynauds/ common in younger women, hereditary
-Secondary raynauds/ vasoconstriction with another condition

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22
Q

Entrapment syndromes

A

Popliteal artery entrapment/popliteal artery is compressed by the medial head of the gastrocnemius muscle. May result in stenosis, aneurysm. Often found in young athletes.

Thoracic outlet syndrome/compression of the Nuro vascular bundle by the shoulder structures. Cervical rib, clavicle, scalene, muscles, numbness, tingling of arm, pain and arm. 

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23
Q

Claudication

A

The most common symptom of peripheral artery disease

Due to inadequate blood flow

Pain usually distal to the disease often in calf

Example/Leriche syndrome- aorta iliac obstruction. More common in males.

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24
Q

Pseudo claudication

A

False claudication

Referred to as neurogenic claudication

Pain due to neurogenic cause / ex- spinal stenosis, or nerve compression

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25
Q

Ischemic rest pain

A

Pain at rest

Inadequate blood flow

Typically affects the toes, foot, heel

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26
Q

Tissue loss

A

Insufficient blood flow to maintain cell metabolism

Gangrene/tissue necrosis

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27
Q

Skin conditions

A

Pallor/white
Rubor/reddish
Cyanosis/bluish

Elevation/dependency changes - pallor with elevation and rubor with dependency.

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28
Q

Blue toe syndrome/trash foot

A

Suggestive of distal micro emboli

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29
Q

Capillary refill times

A

An increase in capillary refill times suggest decreased arterial pressure perfusion

Normal refill time is less than three seconds

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30
Q

Circulatory system

A

Pressure is greatest at the heart, decreasing distally

Cardiac output determines the amount of blood entering the system

Venous return equals cardiac output

Movement of any fluid requires a pathway and a pressure/energy differential

Amount of flow depends on energy difference, and resistance

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31
Q

Circulatory system

A

Arteries/distribute blood to the body

Arterioles/slow flow velocity, increased resistance

Capillaries/nutrient exchange

Venules/collect blood from the capillary beds

Veins/high capacitance blood storage

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32
Q

Blood leaves the heart with a meannn pressure of

A

85 to 95MMHG

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33
Q

Small arteries and arterioles are the

A

Resistance vessels and pressure falls from 80 to 25/30 MM Hg

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34
Q

Blood moves from

A

High pressure to low pressure area

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35
Q

Flow

A

How much blood is moving

Volume

Liters/minute

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36
Q

Velocity

A

How fast the blood is moving/speed

Centimeters/ sec

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37
Q

Flow types

A

Steady flow/constant velocity

Pulsatile/variable velocity due to cardiac contractions

Phasic/variation in velocity and low pressure venous circulation due to respiration

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38
Q

Energy

A

Potential/pressure energy:
The ejection of blood from the heart into the arteries distends the elastic arterial wall, and this becomes stored energy

Kinetic/motion energy :
Movement of blood, as it’s ejected from the heart

Gravitational energy or hydrostatic pressure:
Weight of the column of blood from the heart to the level with the pressure is measured, position a patient

MMHG - pressure

For example, flash and a supine patient the arteries and veins are about the same level as the heart and the hydrostatic pressure is near 0MMHT. When the patient stands, the HP increases adding 100 MM Hg at the ankle.

Ankle pressure standing = circulatory pressure + gravitational(100mmghg)

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39
Q

Energy loss as blood flows

A

Friction (common)- fractional losses occur when one object rubs against another, energy converted to heat

Viscosity (least likely) - thickness of fluid

Inertia and momentum - objects in motion tend to stay in motion and objects at rest and stay at rest. Energy is lost when the velocity or the direction of the fluid changes.

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40
Q

Blood flow patterns

See diagram

A

Laminar flow/fluid particles, flow smoothly in an organized manner. Two types of laminar flow.;
-Plug flow/the last things that are similar from wall-to-wall
-Parabolic flow/flow that is faster in the center of the vessel

Disturbed flow/, disruption of stream lines, Bends, bifurcates, stenosis area

Turbulent flow/flow with varying direction and velocitys, associated with disease

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41
Q

Reynolds number

A

Predicts when stable flow becomes unstable

<1500 means laminar
> 2000 means turbulent flow

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42
Q

Factors affecting resistance

See diagram

A

Movement of fluid depends upon physical properties (blood density, viscosity) and what it’s moving through (blood vessel)

Resistance is directly proportional to viscosity, and length, resistance increases with increasing viscosity and length

Resistance is inversely proportional to the vessel, radius, resistance increases as vessel, radius decreases

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43
Q

Poiseuilles law

A

Flow (Q)= pressure (P) / resistance (R)

Describe the relationship between pressure flow and resistance to flow

Defines how blood moves through a given vessel segment

*Vessel radius, or area, is most important

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44
Q

Pulsatile flow

See diagram

A

Early systole/cardiac contraction, opens

Late systole, early diastole/closes, dicrotic notch represents aortic valve closure

Lake diastole/proves recoil

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45
Q

Waveform morphology

A

High resistance flow:
Forward flow during systole, late systolic flow reversal
Supplies most peripheral vascular beds ; arms, legs, splanchnic vessels, and fasting patients

Low resistance flow :
Forward flow throughout the cardiac cycle
Supplies, Oregon’s with HAIM, metabolic rate, brain, kidneys, vessels after eating, ICA
* low resistance= life

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46
Q

Law of conservation of mass

A

Q=A x V

Area and velocity are inversely proportional

Area decreases, velocity increases

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47
Q

Flow characteristics of a stenosis

A

As blood velocity increases through a stenosis, kinetic (motion)energy increases, and potential (pressure) energy decreases.

Proximal to stenosis/flow pattern, may or may not be altered

At stenosis/velocity increases, flow is disorganized, spectral, broadening

Post stenosis/Turbulence

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48
Q

50% diameter reduction =

A

75% area reduction

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49
Q

An arterial occlusion or stenosis may result in_____ pressure distally.

A

Decreased

(The peripheral resistance will change from high to low)

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50
Q

Systolic acceleration time
(AT)

A

Hemodynamically significant stenosis, may also affect the speed of pulse wave and results in a delayed systolic acceleration time.

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51
Q

Sympathetic nervous system includes

A

Cerebral, coronary, Renal

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52
Q

Collaterals

A

Collateral circulation is an alternative pathway that may supply blood around an obstruction

These collateral vessels, Mesa Place, efficient, blood volume to maintain normal, peripheral resistance and blood flow despite disease

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53
Q

Exercise is a very potent vasodilator

A

Transform flow patterns from high to low resistance

Vasoconstriction at rest = high resistance

Vasodilation = low resistance

Flow to cool Limb- vasoconstriction, high resistance

Flow to warm limb - vasodilation, low resistance

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54
Q

Viscosity

A

Internal friction dependent upon the thickness of the fluid

Increased hematocrit/increased viscosity

Anemia results in decreased viscosity

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55
Q

Hemodynamics

A

Systolic upstroke-shows where the blood came from
(Delayed systolic upstroke means stenosis, proximal)

Diastolic flow - shows where the blood is going
(Resistance of the downstream, vascular bed)

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56
Q

Plethysmography

A

Measurement of blood volume changes as a result of the blood moving through the limb.
2 types

-Volume Plethysmography (PVR)- reflects amount of blood, moving under cuff

-photoplethysmography (PPG)- assessment of cutaneous blood flow. Skin level/ ulcers.

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57
Q

CW Doppler velocimetry

A

Analog/uses zero crossing frequency detector

Digital/spectral analysis
FFT, analyzes and displays all frequencies moving in sample area

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58
Q

Quantitative Doppler waveform interpretation

A

Pulsatility index (PI)-calculates peak to peak frequency difference.
Normal > 4.0
Abnormal < 4.0 consistent with >60% stenosis, proximal to the sample

Systolic acceleration time -proximal obstruction results in delayed time interval, between systole and peak velocity
Normal AT < 133 ms
Abnormal AT > 133 ms proximal obstruction

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59
Q

Inflow/outflow disease

A

Inflow disease/represents the blood flowing into the lower. Ex, aorta, iliac disease.

Outflow disease/represents the blood flow going out into the extremity , ex, for femoral popliteal disease 

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60
Q

Segmental pressures

A

Only detect significant disease. Cannot discriminate normal from mild disease or stenosis from occlusion.

Do not do pressures on patients with;
DVT
fistula or graft
Lymphedema
Post bypass graft with stenting

Four cuff method, two thigh cuff

Three cuff method, single, thigh cuff

  • see diagram

Lower extremity cuff size -
10 to 12 cm cuff for brachial
10 cm calf and ankle
12 cm thigh cuffs for 4 cuff method
19 cm thigh cuff for 3 cuff method

Upper ext. cuff size-
12 cm cuff for brachial
10 cm cuff for forearm

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61
Q

20% rule

A

Width of cuff 20% greater than the diameter of the limb

Using a too small cuff results in artifactually high pressure

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62
Q

4 cuff vs. 3 cuff

A

4 cuff method-
Two thigh cuffs provide a proximal and distal thigh measurement
Differentiates between aorta iliac (inflow) and superficial femoral artery disease
The 2 thigh cuffs violate the 20% rule and will result in artifactually elevated high pressures, and pressures will be 30 mmHg higher*

3 cuff method-
1 thigh cuff
Accurate thigh pressure
If abnormal, cannot differentiate between inflow and SFA disease 

Inflate cuff 20-300 mm/Hg higher than the brachial pressure

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63
Q

ABI interpretation

A

> 1.0- normal
In between/ probably abnormal
< 0.5- multi level disease or occlusion
Under is ischemic pain

ABI of > 1.3 is not valid/ calcified

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64
Q

Wound healing

A

Toe pressure 30mm/Hg or less has very poor healing potential

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65
Q

Segmental pressure interpretation

A

Lower extremity
> 20 to 30 abnormal

Upper extremity
> 15 to 20 abnormal
A difference of >20 mmhg between the radial and ulnar, suggests obstruction in the vessel with the lower pressure 

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66
Q

Exercise testing

A

The most common symptom of peripheral artery disease is exertional pain

Exercise testing allows the differentiation of vasculogenic claudication from pseudo claudication, such as neural spinal compression or arthritic pain

There will always be a pressure drop when patient experiences the pain of true vasculargenic claudication 

Normally, the ankle pressure should be the same or higher

Post treadmill -
Larger the drop longer return to baseline corresponds to lesion severity. Drop in ankle >20 confirms vascular ideology for claudication

*Length of time to recover -
2 to 6 minutes single level disease
6 to 12 minutes multilevel disease

Post occlusive reactive hyperemia
Normal Limb Michelle at transient drop of up to 30%
< 50% drop single level disease
> 50% drop multilevel disease

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67
Q

Digit interpretation

A

Functional disease/consistent with vasospasm
Baseline/resting -normal Doppler, PPG, waveforms and pressures
Abnormal cold response -fails to return the Baseline
Peaked pulse seen with Raynauds

Finger brachial index
Normal 0.8 to 0.9.
Abnormal < 0.8.

Tell brachial index
Normal > 0.75.
Abnormal < 0.66.

<30 mm/Hg = poor healing potential

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68
Q

Lower extremity artery

A

Velocity ratio= highest PSV in the stenosis divided by the PSV proximal to the stenosis

2:1 ratio > 50% diameter reduction
4:1 ratio > 75% diameter reduction

PSV > 400 cm/s = > 75% reduction 

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69
Q

Aneurysm

A

Peripheral artery aneurysm- dilated artery > 1 1/2 times the diameter of the adjacent artery

Patience with an aneurysm in one location or more likely to have an aneurysm elsewhere

Embolization is the most like a complication for peripheral aneurysms

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70
Q

Aorta iliac artery duplex imaging

See diagram 

A

AAA-
Dilated segment > 1 1/2 times the diameter of the normal artery segment
Infra renal/ most common
Supra renal/uncommon

Aneurysm/rupture
Peripheral/emboli

71
Q

Stenosis, interpretation, iliac, arteries

A

2:1 ratio increase= > 50% diameter reduction

4:1 ratio increase= > 75% diameter reduction

72
Q

Upper extremity artery imaging

See summary chart

A

Interpretation:
-Aneurysm:
subclavian artery aneurysm, most common, associated with distal emboli.
Ulnar artery aneurysm typically secondary to Hypothenar hammer syndrome, trauma. 

Hypothenar hammer syndrome/
Repetitive blunt trauma to the superficial palmar arch of the owner artery

73
Q

Arterial duplex following intervention

A

Bypass grafting:
Used to round blood around the occluded segment

Named for type of graft and location, for example, aorta bifemoral , a bifurcated graft from the aorta to the CFA bilaterally, aorta iliacs occluded

Extra anatomic/placed, where a vessel does not typically run

Grafts are made of :
-synthetic/ polytetrafluorethylene (PTFE) or dacron (plastic)
-autogenous vein/ uses patients own vein or artery to create. *common for stenosis. Two types, in situ and reversed.
*In sutu tributaries not ligated may become arteriovenous fistulas.

Anastomosis/the connection of the bypass graft to the artery

Higher velocities, through stent

Native arteries 2:1 ratio = > 50% stenosis

74
Q

Most common site of stenosis and grafts

A

Vein grafts- retained valves

Synthetic grafts- anastomosis

75
Q

Endovascular aneurysm, repair

EVAR

A

Catheters used to position a graft inside of the aneurysm, expanded, and then hooked in the place with stents

Most commonly performed on AAA

76
Q

Endoleak

A

Flow within the aneurysms sack outside of the graft walls

**
Type 1- leak from the attachment site
Type 2- patent branch with retrograde flow into the aneurysm
Type 3- graft defect
Type 4- graft porosity, flow through holes in the material
Type 5- endotension, enlarging aneurysm sac with no detectable leak.

77
Q

Intravascular Ultrasound
IVUS

A

Tiny transducer at the top of a catheter provides an image from inside out

78
Q

Pseudoaneurysm

A

Fake aneurysm
CFA is the most common site

A defect or hole in the arterial wall typically from trauma and often hospital acquired, such as catheterization

To and fro flow pattern

79
Q

Anteriovenous Fistula
AVF

A

An abnormal connection between the high-pressure arterial system, and the low pressure venous system

Congenital or traumatic

High velocity’s in the connection
Erratic at beginning of connection
See diagram

80
Q

Entrapment syndromes 

A

Thoracic outlet syndrome (TOS)
Compression of nerves, arteries, veins
Common and athletes
Three main types, neurogenic (most commo) Venus, reduced venous, outflow and arterial, reduced arterial blood flow

Popliteal artery entrapment syndrome (PAES)
Dorsiflexion, gastrocnemius muscle contraction, results in compression of the pop artery

81
Q

Arteritis

A

Buergers Disease
Typically affects small vessels in upper and lower extremities (hand, foot) Occurs primarily in men < 40 years, heavy tobacco abuse

Takayasus Arteritis
And tomorrow, fibrosis and vascular narrowing, most commonly affecting large arteries, usually the aorta and its main branches. Often young women of Asian dissent. Pulseless disease.

Temporal arteritis
Inflammation of the arterial wall of the superficial temporal artery. May lead to blindness, often described as halo.

82
Q

Vasospastic disorders

A

Raynauds phenomenon
The arterial spasm results and decrease blood flow typically affecting the fingers. Two main types;
Primary Raynauds/most common, vasospasm only
Secondary Raynauds/vasospasm with a secondary cause and tissue that necrosis
* see picture

83
Q

Penile imaging

A

Anatomy(see picture)-
Dorsal arteries
Cavernosal artery
Superficial and deep dorsal vein

Penile brachial index
Normal > 0.75.
Abnormal < 0.65 (impotence)

Diameter of cavernosal arteries should increase post injection
Flow resistance/ High pre-injection, low post injection. PSV should increase >30cm/ sec, less than 30 is abnormal

Dorsal vein velocities should not increase. And increase is suggestive of Venus leak.
Normal <3cm/sec
Abnormal >20

84
Q

<30 mmHg ——-

A

Poor healing potential

Wound unlikely to heal

85
Q

Hydrophone

A

A microphone that detects sound waves underwater

Today used to test, power and intensity levels by the ultrasound beam

86
Q

Allen’s test

A

Tests the patency of the Poolmart arch

Radial and ulnar artery is are manually compressed

Ulnar released, observe for refilling. Repeat radial.

Normal colors should return in < 10 seconds

87
Q

Preoperative arterial mapping

A

See chart

88
Q

Visceral artery duplex imaging

A

Anatomy (see pic)
Celiac artery : left gastric artery, common hepatic artery, splenic artery
SMA
Renal arteries
IMA

Mesenteric artery : (see picture)
Achy or crampy abdominal pain 15 to 30 minutes post prandial

Two Possible connections between the SM A, and IMA
-Marginal artery of the colon (marginal artery of Drummond)
-arc of riolan

SMA/preprandial, high resistance, and post prandial converts to lower resistance

89
Q

Extrinsic compression

A

AkA- Median arcuate ligament syndrome

Compression of the celiac artery origin by the median arcuate ligament of the diaphragm

Rarely symptomatic

90
Q

Renal artery, duplex

A

Identify renal stenosis before Reno failure

Most hypertension is called
“essential hypertension” - that is from no direct identifiable cause.

Secondary hypertension is
hypertension that is the result of some other disease, commonly of the kidney.

**Renal artery stenosis may cause the release of renin, promoting conversion of angiotensinogen to angiotensin, causing vasoconstriction and subsequent high blood pressure. This is called renovascular hypertension.
Eventually results in renal failure.

91
Q

Reno aortic ratio

A

RAR = highest renal artery, PSV, divided by aorta PSV

Normal < 3.5
Abnormal > 3.5 consistent with 60% or greater diameter reduction.

Do not use if AAA is present or aortic PSV < 40 or > 90 cm/s

Resistivity Index (RI)
RI= PSV - EDV/PSV
Normal < 0.8
Abnormal >0.8

End Diastolic Ratio (ED)
Parenchymal Resistance Ratio
EDR = EDV/PSV
Normal > 0.2
Abnormal < 0.2

92
Q

Acceleration time
AT

A

Helps determine proximal stenosis

Obtained from the distal renal artery at the hilum

Normal < 100 ms
Abnormal > 100 ms, consistent with >60% stenosis proximately

Delayed time = stenosis

93
Q

A lesion in the mid or distal renal artery segment is typical of

A

Fibromuscular dysplasia

94
Q

Renal transplant

A

Renal vein anastomosed to the external or internal iliac vein

Renal artery anastomosed to the external or internal iliac artery

Diagnosis of rejection -biopsy

95
Q

Hemodialysis access evaluation

A

High blood flow volumes

Types of dialysis access:
-synthetic grafts/material used to connect an artery to a vein
-Native autogenous fistula/ vein is connected directly to the artery. Fistula will mature and vein dilate in response to the artery pressure.
-Breccia cimino fistula-describe a radial artery to cephalic vein fistula

Inflow artery, outflow vein

Bruit or thrill normal

Venus anastomosis and outflow vein most common sites of stenosis

96
Q

Hemodialysis velocity criteria

A

General velocity criteria for >50% stenosis
At the anastomosis
• PSV > 400 cm/s
• Velocity ratio >3
• Intraluminal defect
Along the venous outflow
• PSV > 300 cm/s
• Velocity ratio > 2
• Velocities <50 cm/sec

Normal/high velocity, low resistance
Abnormal/high resistance, or decreased systolic upstroke

Volume flow interpretation
Normal > 800 ml/min
<500 ml/min suggestive of a failing access

97
Q

Hemodialysis
Velocity versus volume flow

A

Velocity
Identify a stenosis
Does not relate to performance of
access
Useful to follow trends in individual patients

Volume flow
Indicates performance of access
Suggest, but does not identify stenosis
Useful to follow, trans an individual patience

98
Q

Hemodialysis pathologies

A

Extravascular mass/anechoic mass with no flow (seroma, hematoma, thrombosed, pseudoaneurysm)

Pseudoaneurysm

No thrombin injections on dialysis patients

Axis aneurysm

Steel syndrome/arterial flow distal to fistula is reversed, flowing into the venous circulation, fistula, steals, radial, and ulnar blood

99
Q

Cerebrovascular

See pic

A

ICA. Is the primary blood supply to the brain, low resistance, approximately 80% of the volume moving through the CCA travels into the ICA.

ECA has a branches, supplies, the face and scalp, high resistance
* first branch off of ECA/superior thyroid
Facial and superficial temporal artery branches

Collateral pathways
ECA - ICA via ophthalmic and orbital arteries
Occipital branch of ECA with Atlantic branch of vertebral
Cervical subclavian branches to vertebral artery branches

Largest collateral pathway is the circle of Willis (pic)

100
Q

Cerebrovascular pathology
Atherosclerosis

A

Atherosclerosis (ASO)/
Most common pathology affecting their carotid vessels

Types of Atherosclerotic plaques
Fatty Streak - thin layer of lipid material in intimal layer
Fibrous Plaque - accumulation of lipids
Complicated lesion - a fibrous plaque that includes fibrous tissue and collagen
Ulcerative lesion - fibrous cap deteriorates - increased incidence of embolus
Intraplaque hemorrhage - rupture of the vaso vasorum with bleed inside the plaque

101
Q

Cerebrovascular pathology
Fibromuscular dysplasia

A

Most common in distal ICA

Rare condition/cellular growth in the walls of the medium and large arteries

Common in women

Irregular appearance of the lumen

102
Q

Cerebrovascular pathology
Neointimal hyperplasia

A

Occurs after endarterectomy/trauma

Intimal thickening from rapid, smooth muscle cell growth

103
Q

Cerebrovascular pathology
Carotid, body tumor

A

Carotid body is a small sensory organ just above the bifurcation

AKA/ paraganglioma

Usually fed by branches of the ECA

104
Q

Cerebrovascular pathology
Carotid dissection

A

Tear in the intimal lining

Creates false lumen

105
Q

Cerebrovascular pathology
Aneurysm

A

Rare in carotids

1.5 x’s normal diameter

106
Q

Transient ishemic attack

A

TIA
Temporary cut off of blood flow

107
Q

Cerebrovascular symptoms
Lateralizing symptoms
Hemispheric symptoms that are contralateral
Ex-right hemisphere CVA affects left side of body

A

TIA/resolve completely within 24 hours
Resolving ischemic neurologic deficit/last longer than 24 hours but resolve
Completed stroke/permanent

Paresthesia- Tingling, pins and needles, prickling of the skin

Paresis-Weakness, numbness, or paralysis

Hemiparesis -Weakness, numbness, or paralysis on one side of the body

Hemiplegia-Paralysis on one side of the body

Aphasia -Inability to speak

Dysphasia -Difficulty speaking, loss of power of verbal expression

Dysarthria -Difficulty with speech due to the dysfunction of the muscles o nerves involved with speaking

108
Q

If an ICA lesion embolize is to the——

A

*ACA/ likely to affect the leg more than the arm

*MCA/likely to affect the arm

Dysphasia likely to be MCA

109
Q

Cerebrovascular symptoms
Non-lateralizing

A

Terminology:
Dizziness-impairment in spatial, perception, and stability

Dyssynergia (ataxia)-lack of muscular coordination

Diplopia-double vision

Drop Attack-sudden fall without loss of consciousness

Dyslexia-difficulty reading, or interpreting words

Syncope-sudden loss of consciousnes

Vertigo-difficulty with equilibrium

110
Q

Amaurosis fugax

A

Loss of vision in one eye on ipsilateral side

Ex: right ica embolus to the right ophthalmic artery who would result in right amaurosis fugax

111
Q

Homonymous hemianopia

A

Last of the visual field of view that impacts both eyes

Right brain hemisphere damage may result in a left homonymous hemianopia and the last of the left field of view in both eyes

112
Q

Hemispatial neglect

A

Example left hemispatial neglect, may result in damage to right hemisphere

Impaired body position or spatial orientation on one side of the body

113
Q

Main symptoms highly associated with carotid artery disease

A

Hemiparesis
Aphasia/dysphasia
Amaurosis fugax

114
Q

Hollenhorst plaque

A

A cholesterol embolus that typically originates from the ipsilateral carotid artery, travels into the ophthalmic artery, and lodges in a blood vessel of the retina

Possible emboli from ICA/ aorta/heart

115
Q

Cerebrovascular velocities

A

See pic
Pg178

116
Q

Bilateral abnormal upstroke

A

Cardiac issues

117
Q

Vertebral artery

A

First branch arising from subclavian artery

Joint in the posterior aspect of the brain to form basilar artery

118
Q

Subclavian steal

A

Occlusion of the subclavian artery with flow, traveling up one vertebral artery, down the contralateral artery in via the best seller artery to supply the arm

119
Q

Subclavian artery

A

Stenosis/occlusion more comment on the left

Blood pressure differential between arms >15-20 mm/hg

120
Q

ICA / CCA ratio

A

PSV in the ICA / PSV distal CCA

Normal ICA / CCA ration < 2.0

> 4.0 70% threshold

121
Q

NASCET

A

North American symptomatic carotid endarterectomy trial

> 50% stenosis , > 180 cm/s PSV
70% stenosis, > 260 cm/s PSV

Trial that determined the efficacy for carotid artery disease

122
Q

Carotid artery intervention

A
  • endarterectomy/surgical procedure in which the artery is isolated and opened, plaque is removed, artery sutured closed

-Angioplasty with or without stent/balloon catheter, is passed into the artery and positioned within the stenosis. Balloon is inflated, opening lumen, and then deflated and removed.

Post endarterectomy -intimal hyperplasia most common 3 to 24 months and recurrent atherosclerotic disease > 24 months

123
Q

Transcranial Doppler

A

Circle of Willis (see pic)
Anterior communicating artery
Anterior cerebral arteries
Small portion of the distal ICA
Posterior communicating arteries
Posterior cerebral arteries

  • middle cerebral artery as an extension of the ICA and not part of the circle of Willis

Ophthalmic artery branches off of the terminal ICA

Supraorbital artery arises from the ophthalmic artery, notably, the Superficial temporal artery

Frontal artery arises from the ophthalmic artery, exits, the orbit to supply the forehead

  • transorbital approach- follow ALARA
124
Q

Transcranial Doppler 

A

2 MHz Doppler

Zero angle of incidence

Mean velocity used, not PSV

Three acoustic windows -
Transtemporal (ICA, MCA, ACA, PCA)

Transorbital (opthalmic art, carotid siphon)

Transforamenal/ Sub-occipital (distal vertebral, basilar arteries)

125
Q

Factors that may alter intracranial blood flow

A

Age
Sex
Hematocrit
Arterial blood gas
Metabolic demands

126
Q

Transcranial Doppler
Collateral pathways

A

Crossover/antegrade flow in the ACA from crossover collaterization

ECA to ICA; retrograde flow in the ophthalmic artery

Posterior to anterior/increase flow in the posterior cerebral artery with reversed low in the posterior communicating artery

127
Q

Sickle cell disease

A

Most common inherited disorder of the blood

Number of red blood cells decreases from rupture, anemia results

Affects primarily Africans

128
Q

Transcranial Doppler
Vasospasm

A

• Most accurate in the MCA

Mean Velocity >120 cm/sec
Severe vasospasm >200 cm/sec

129
Q

Transcranial Doppler
Micro emboli detection

A

Gas or solid microemboli within the MCA can be detected by TCD as H
Transient Signals (HITS), also called micro-embolic signals (MES).
• Characterized by:
Duration <300 milliseconds
Higher amplitude than the background blood flow signal;
Typically, unidirectional and occur randomly
Characteristic sound like a “moan” or “chirp” on audio

The emboli comes from carotid stenosis

PFO/ patentamen ovale-
Hole in heart, blood/emboli travel from venous circulation to arterial

130
Q

Transcranial Doppler
Transmandibular acoustic window

A

Can access the mId and distal segment of the ICA

Is primarily for emboli monitoring

131
Q

Venous anatomy

A

Same three layers as arteries
Intima
Media/thin compared to artery
Adventitia/thickest layer

Peripheral veins, return, deoxygenated blood to the heart/right atrium

Veins with valves -
*Infrainguinal deep veins increase in number, distally, especially infrapopliteal
*GSV has as many as 10 to 20
Small saphenous, 6 to 12

Veins without valves -
SVC/IVC
*Soleal veins/ sinuses
Intracranial

132
Q

Venous anatomy
Divided into three systems

A

-superficial system/change the skin and subcutaneous tissues, empty into the superficial truncal veins or directly into the *deep system

Perforated veins/perforate the facia and connect the deep and superficial system

Deep system/carries 85 to 90% of the blood out of the lamb

133
Q

Superficial venous system

A
  • drain the skin and subcutaneous tissues

Two primary superficial truncal veins:
-GSV/ has its own fascial compartment, longest vein in the body. Immediately from foot to the CFV forming the saphenofemoral junction

-SSV/ origin is dorsal, venous arch, termination, often a pop, but highly variable

True trunks are contained within the saphenous fascia

134
Q

Accessory saphenous systems

A

Anterior accessory, great saphenous vein ( AAGSV) / alignmen sign, aligns with the superficial femoral artery

Posterior accessory great saphenous vein (PAGSV) / ** enlarges with pelvic congestion. Posterior thigh, termination, GSV. Often leg source of posterior thigh varicosities

135
Q

Venous anatomy
Other Important veins

A

Superficial epigastric vein(SEV) /
Drains the skin of the lower abdomen
* an important landmark for venous interventional procedures

Giacomini Vein/ connects, the SSV with the GSV or joins the posterior accessory that joins the GSV. Plays a role in the development of chronic venous disease.

Perforating veins /perforate the fascia, and carry blood from superficial veins into the deep veins

136
Q

Perforating veins from groin to foot

See pic

A

Saphenofemoral Junction
GSV
Perforators of the femoral canal
Paratibial Perforators
Posterior tibial perforators
Medial ankle perforators

137
Q

Venae comitantes

A

A pair of veins, occasionally more, that closely accompany an artery.

Most deep veins!

138
Q

Gastrocnemius veins

A

Paired vein sets

Within the gastrocnemius muscle of the calf, companion artery, join the popliteal vein

139
Q

Soleal veins

A

Within the Solias muscle, drain into the calf veins

No paired artery

140
Q

Lower extremity venous sinuses

A

Major component of the calf muscle pump

Drains blood into PTV, Pero

Soleal/gastrocnemius muscles

141
Q

Pop V

A

Formed by the ATV and tibial, peroneal trunk

142
Q

Femoral Vein

A

Passes through adductor hiatus

Terminates in Scarpas triangle

143
Q

Profunda /deep femoral vein

A

Ascends deep and lateral to the femoral vein

144
Q

External iliac vein

A

CFV becomes the EIV as it passes beneath inguinal ligament

Joins the internal iliac vein to form the common iliac

145
Q

Internal iliac vein

A

Ascends through pelvis

Drains the pelvis

146
Q

IVC

A

Formed by the common iliac vein’s

Penetrate the diaphragm and terminates in the right atrium

147
Q

Renal veins

A

Drain the kidney and suprarenal glands and empty into the IVC

148
Q

Portal venous system

A

Portal vein/formed by superior mesenteric and splenic veins. Drains, abdominal digestive, tract, pancreas, spleen, gallbladder.
* carries blood into the liver
* carries 80% of blood flow into liver

Hepatic veins/drains liver, empties into IVC, carries blood away from liver

149
Q

Upper extremity veins

A

Superficial:

Basilic vein/
Empties the medial aspect
Joins brachial vein to form axillary vein
Can be harvested for bypass

Cephalic/
Formed by digital veins
Empties lateral aspect
Joins axillary to form subclavian
Can be used for bypass

Deep:

Radial/ formed by deep, palmar, arch, empties lateral hand and forearm

Ulnar/ formed by superficial palmar, arch, empties, medial hand, and forearm

Brachial/ formed by radial and ulnar

Axillary/foreign by brachial and basilic

Subclavian/formed by axillary and cephalic 

150
Q

Innominate vein

A

Brachiocephalic vein

Formed by subclavian and internal jugular veins

151
Q

IJV

See pic

A

Collects blood from brain, face and neck

152
Q

Intracranial, venous sinus

A

Drains blood into IJV

153
Q

Central veins

A

Superior vena cava
Formed by innominate vein’s
Trains, head, neck, upper extremities
Terminates in right atrium

Inferior vena cava
Formed by common iliac vein’s
Drains lower half of body
Terminates in right atrium

154
Q

Venous hemodynamics

A

Venous system:
Serves as a reservoir for blood
Approximately 2/3 of total blood volume resides in the venous system
Returns blood to the heart
Venous return = cardiac output
Affective venous return requires;
Central pump(heart)
Pressure gradient
Peripheral venous pump
Competent venous valves

155
Q

Two main types of pressure in the venous system

A

Dynamic pressure and hydrostatic pressure

Dynamic pressure :
From the cardiac contraction
Drives blood through the system
When supine/ 8mm/Hg in the leg and 0 mm/Hg at the right atrium
* due to the low venous pressure, respiratory motion, influences venous return

Hydrostatic pressure :
The weight of the column of blood from the heart to any given spot on the body

Hydrostatic pressure = pgh
p = specific gravity of blood Den rite
g = acceleration of gravity
h = height (distance from the heart)

The hydrostatic pressure at the ankle of a normal height person STANDING is approximately 100 mm/Hg.

What about body part above the right atrium?
• Negative hydrostatic pressure would be
= - 50 mm/Hg
• But veins collapse at 0 mm/Hg

O mm/Hg is the minimum measurable

Standing and raising right arm -50

156
Q

Inspiration/expiration

A

Inspiration - Lowers the diaphragm, decreases intra-thoracic pressure AND increases intra-abdominal pressure -
•Decreased venous return from the lower extremities
•Increased venous return from the upper extremities

Expiration - Raises the diaphragm, increases intrathoracic pressure AND decreases intra-abdominal pressure
• Increased venous return from the lower extremities
• Decreased venous return from the upper extremities

157
Q

Ineffective calf muscle pump or outflow obstruction

A

Results in venous, pooling and ambulatory venous hypertension

158
Q

Venus properties

A

The volume of blood carried by the arteries is the same because Cardiac output= venous return

Compliance - Ability to accommodate a large change in Volume with a small change in Pressure

Capacitance - Ability to accommodate a large change in Volume in a short period of Time

159
Q

Transmural pressure

A

Transmural Pressure

Relative pressure difference from within the vessel (intravascular pressure) to the out (tissue pressure)
**By convention, this is always referenced from the inside of the vessel
When tissue pressure exceeds the intravascular pressure, the transmural pressure is considered low, and the vessel “collapses”

** high venous pressure/low tissue pressure

** Low, venous pressure/high tissue pressure

Low transmural pressure/collapsed vein -higher pressure

160
Q

Virchows triad

A

Trauma
Stasis
Hypercoagulability

161
Q

Venus thrombosis

A

1) trauma (blunt, or surgical)
-Paget scheoetter syndrome/involves axillary and subclavian veins, may be component of thoracic outlet syndrome
-PICC line/catheter damages, venous, endothelium. Thrombus often occurs at the proximal end of the PICC line.

2) venous stasis/decreased venous return
Ex: and mobility, obesity, COPD, long flight(coach class syndrome) previous DVT

3) hypercoagulability/when your blood clots
Ex: protein deficiency, hormones, pregnancy

162
Q

Phlegmasia cerulea dolens

A

bluish discoloration due to severely limited venous outflow, a precursor to gangrene.

163
Q

Phlegmasia alba dolens

A

white discoloration, “milk leg” compromised arterial inflow

164
Q

Continuous flow

A

In a vein can= proximal obstruction

165
Q

Rouleaux formation

A

Red blood cells arranging a stack like a roll of coins

Sluggish flow

Most likely normal, but could indicate slow flow due to proximal obstruction

166
Q

Venous reflux

A

Retrograde flow

167
Q

Cephalad

A

Normal flow

168
Q

IVC tumor

A

Renal cell carcinoma is the most common solid renal mass in the adult

Tumor invades the renal vein, extending into the ivc

The most common cause of IVC tumors as a renal cell carcinoma

169
Q

May Thurner syndrome

A

Iliac compression syndrome

170
Q

Nutcracker syndrome

A

Left renal vein compression

Results in renal venous hypertension

Dilatation of the ovarian or gonadal vein’s, contributes to pelvic congestion syndrome

171
Q

Budd Chiari syndrome

A

Result of hepatic vein occlusion

172
Q

Portal hypertension

A

Increased blood pressure in the portal vein, the most common cause is cirrhosis

Treatment/transjugular intrahepatic portosystemic shunt (TIPSS)

The most common cause of cirrhosis

173
Q

Tourniquet interpretation

A

Tourniquet Interpretation
Superficial system incompetence = Abnormal VRT ≤ 20 secs without tourniquet but normalizes (>20 seconds) with tourniquet

174
Q

Statistics

A

Chapter 29
Page 281

ESP Vascular (1 decks)

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