Week 10: Upper Extremity Arterial Scanning

Question 1

Upper extremity arterial imaging is ____ common than lower extremity arterial imaging because significant atherosclerotic obstructive disease in the arms is much less common than in the legs

Answer 1

less

Question 2

1. Right common carotid artery: Begins at the ____ and ends at the ____
2. ** Left common carotid artery**: Begins at the ____ and ends at the carotid bifurcation
3. Innominate artery (AKA: ____): Begins at the aortic arch and ends at the bifurcation into the____ and ____

*Only one innominate artery

Answer 2

1. innominate bifurcation, carotid bifurcation
2. aortic arch
3. brachiocephalic, right common carotid, right subclavian arteries

Question 3

Identify 1-7

Answer 3

1. right subclavian
2. thoracic outlet
   3.axillary artery
   4.brachial artery
   5.radial artery
   6.ulnar artery
   7.antecubital fossa

Question 4

Anatomy:
Subclavian arteries become the ____ arteries as they pass under the clavicle and over the first rib to exit the thoracic cavity called ____

Answer 4

axillary
thoracic outlet

Question 5

Anatomy:
Axillary artery: Begins at the thoracic outlet and ends at the insertion of the ____ in the upper arm then becomes ____

Answer 5

teres major muscle
brachial artery

Question 6

Anatomy:
Brachialartery: Begins at the insertion of the ____ and ends at the bifurcation into the ____ and ____ arteries slightly distal to the level of the ____

Answer 6

teres major muscle
radial, ulnar
antecubital fossa

Question 7

Normally ____ artery is a dominant artery

Answer 7

radial

Question 8

For arms, the BP difference > ____mmHg indicates obstruction of the artery

Answer 8

20

Question 9

Anatomy:
1. Radialartery: Begins just distal to the antecubital fossa and ends at the ____
2. Runs near the radius, staying ____ most of the way through the forearm to the ____ (thumb) side of the wrist

Answer 9

1. palmar arches
2. superficial, lateral

Question 10

1. ____:Begins just distal to the antecubital fossa and ends at the palmar arches
2. Runs ____ towards the ulna and more superficial as it approaches the medial (pinky) side of the wrist

Answer 10

1. Ulnar artery
2. medially

Question 11

Anatomy:
1. Entire upper limb
2. Segment from the shoulder to elbow
3. Segment from the elbow to the wrist

Answer 11

1. Upper Extremity
2. arm
3. Forearm

Question 12

Anatomy: definition
1. Upper Extremity
2. arm
3. Forearm

Answer 12

1. Entire upper limb
2. Segment from the shoulder to elbow
3. Segment from the elbow to the wrist

Question 13

Upper Extremity Arterial Imaging:
Name the direct imaging

Answer 13

Duplex imaging
-Produces a sonographic image

Question 14

Upper Extremity Arterial Imaging:
Name the indirect imaging (4)

Answer 14

1. CW Doppler
2. segmental limb plethysmography
3. PVR (pulse voume plethhysmography)
4. PPG (photoplethysmography)

*Plethysmography is used to measure changes in volume in different parts of the body. The test may be done to check for blood clots in the arms and legs.

Question 15

Upper Extremity Arterial Duplex: Indications? (2)

Answer 15

1. rule out clot
2. assessment of the radial artery

Question 16

What is the most common reason for UE arterial scanning?

Answer 16

1. assessmnt of the radial artery
   2.

Question 17

What is the purpose of the assess the radial artery for? (2)

Answer 17

1. for coronary artery bypass conduit
2. part of a radial-to-cephalic dialysis fistula *starting as distally as possible

Question 18

Signs & Symptoms for UE arterial Duplex (5)

Answer 18

1. UE pain/discomfort
2. arm/hand asymmetry
3. discolored fingers
4. temperature difference between hands/fingers
5. ulcers on the fingertips

Question 19

TDR

Question 20

Patient posistion for UE arterial Duplex?

Answer 20

supine or semi-Fowlers position

Question 21

What test is performed on the each image?

Answer 21

image left: Axillary and brachial arteries - arm abducted and externally rotated or arm up and elbow bent- forming a 90-degree angle

image right: Radial and ulnar arteries: arm extended with the hand in a supinated position (palm up)

Question 22

Scan Technique
Start in a____ plane starting at the proximal neck -just inferior to the ____

Answer 22

TRV, mandible

Question 23

Scan Technique
Return to a TRV probe orientation, angle inferiorly at the level of the proximal clavicle (________) to obtain images of the innominate artery
-Probe @ the suprasternal notch -Utilize color and spectral Doppler

Answer 23

suprasternal notch

1. RCCA
2. RSCA
3. INOM

Question 24

Scan Technique
1. Keeping the probe in a TRV orientation, slide the probe across the clavicle, angling slightly ____, to obtain images of the subclavian artery
2. May need to move the probe inferior to the clavicle and angle ____ for the mid/distal portions
3. Subclavian artery is ____ to the subclavian vein

Answer 24

1. inferiorly
2. superiorly
3. superior

Question 25

**Scan Technique** - At the axillary level, obtain TRV and SAG images of the axillary artery - Axillary artery lies ____ to the axillary vein - Utilize color and spectral Doppler in a SAG plane

Answer 25

lateral

Question 26

**Scan Technique** 1. Distal to the axilla, obtainTRV and SAG images of the **brachial artery** 2. Runs along the inner aspect of the arm to the elbow 3. Has ____ paired veins called:____ adjacent to the artery 4. Utilize color and spectral Doppler in a SAG plane

Answer 26

2, brachial veins

Question 27

Name the vessel 1-2

Answer 27

1. brachial veins 2. brachial artery

Question 28

1. Moving distally, the **brachial artery** bifurcates into the ____. 2. With the palm supinated, on the **lateral** side (thumb) obtain TRV and SAG images of the ____ 3. It runs along the ____ side of the forearm 4. It has ____ paired veins called: ____ adjacent to the artery 5. Utilize color and spectral Doppler in a SAG plane

Answer 28

1. forearm 2.radial artery 3.thumb/lateral 4. 2, radial veins

Question 29

**Scan Technique** 1. Moving distally, the brachial artery bifurcates into the forearm. With the palm supinated, on the medial side obtain TRV and SAG images of the ____ 2. It runs along the ____ side of the forearm 3. It has ____ paired veins called:____ adjacent to the artery 4. Utilize color and spectral Doppler in a SAG plane

Answer 29

1. ulnar artery 2. pinky/medial 3. 2, ulnar veins

Question 30

Name of the vessel?

Answer 30

ulnar artery

Question 31

**Scan Technique** 1. Moving distally into the ____ and ____ 2. ____ performed for a typical UE arterial duplex exam 3. ____ typically used for a quicker assessment of the arterial signals

Answer 31

1. palmar arch, digital arteries 2. Rarely 3. CW Doppler

Question 32

Name the vessels from A to F

Answer 32

A: innominate artery B: subclavian artery C:Axillary artery D: Brachial artery E: Radial artery F: Ulnar artery *Note: further you go, higher the resistence

Question 33

**Normal angle corrected PSVs for the UE arteries:** 1. Subclavian & axillary: ____ cm/s 2. Brachial: ____cm/s 3. Radial & ulnar: ____ cm/s -Palmer arches & digits: lower than PSVs above 4. Note that > _____mmHg difference is abnormal

Answer 33

1. 50-100 2. 50-100 3. 40-90 4. 20

Question 34

No universally accepted velocity cut off points that determine the severity of a stenosis in the UE arteries. However, if there is a ________of the PSV across a stenosis compared with the proximal normal segment, this indicates a <____ diameter reduction/stenosis More severe stenosis will further _____ systolic and diastolic velocities

Answer 34

doubling , 50%, increase

Question 35

Most common cause of stenosis within the UE arteries is ______

Answer 35

atherosclerotic plaque

Question 36

Usually atherosclerotic plaque develops in the ____ and occasionally the ____ -Proximal subclavian arteries can be difficult to see due to vessel depth, size, and geometry -In this situation, diagnosis can be made by **indirect signs** such as high-velocity jets, turbulence, or post stenotic dampening

Answer 36

proximal subclavian arteries, axillary arteries

Question 37

1. Acute frequently caused by ____ from the heart 2. occur most commonly in ____, ____ & ____ due to the smaller vessels 3. The vessel lumen may appear clear on a 2D image, but there will be an ____of flow with color and spectral Doppler

Answer 37

1. embolization 2. brachial, radial, ulnar 3. absence

Question 38

What is AVM?

Answer 38

**atriovenous malformation**: an abnormal connection of veins and arteries which distrupts normal blood flow and O2 circulation

Question 39

AVM 1. is usually ____ 2. can be palpable area 3. can have a blueish tint to it on the skin

Answer 39

1. congenital 2.

Question 40

**AVM** 1. Very well seen with color Doppler as a region of high vascularity 2. Spectral Doppler will demonstrate ____, ____ waveforms within the malformation

Answer 40

low-resistance, high-volume flow

Question 41

**Aneurysms & Pseudoaneurysms** 1. **Rare** 2. Can present as **visible pulsatile swelling** over the area of concern 3. **Aneurysms **are most seen in the ____ associated with ____ 4. **Pseudoaneurysms** are most seen in the ____, ____, and ____ arteries following **arterial puncture for catheter access**

Answer 41

3. subclavian artery, thoracic outlet syndrome 4. radial, brachial,axillary

Question 42

**Aneurysms vs Pseudoaneurysms**

Answer 42

aneurysm of subclavian artery

Question 43

**Aneurysms vs Pseudoaneurysms**

Answer 43

pseudoaneurysm

Question 44

What is TOF?

Answer 44

**Thoracic Outlet Syndrome** - Agroup of disorders that occur when arteries or nerves in the space between the collar bone and first rib (the thoracic outlet) are compressed

Question 45

**TOF** 1. Can cause pain in the shoulders and neck and numbness in the fingers 2. Causes: Physical trauma (ex: car accident), pregnancy, anatomical defects (ex: having an extra rib), repetitive injuries from job or sports related activities 3. More comm on in **females **than males 4. Arteries involved can be evaluated with CW Doppler or Duplex imaging

Question 46

**Duplex Evaluation of TOS** 1. Have the patient in a ____ position so that certain provocation maneuvers can be performed 2. The subclavian artery is imaged from ____ to ____ with the armatrest 3. The subclavian artery is then imaged using any of the **provocation maneuvers** that were found to reduce or obliterate the radial artery signal (done prior to duplex imaging with CW Doppler pencil probe) For example: (4) 4. Any changes in the flow pattern or areas of significant velocity increase along the subclavian artery during provocation maneuvers should be recorded

Answer 46

1. sitting 2. proximal to distal 3. Hyperabduction, Abduction with arm externally rotated, Raise/lower the arm, Rotate head to either side

Question 47

Question 48

Normal appearance of UE arteries (3)

Answer 48

1. high resistive flow 2. triphasic at rest 3. changes in external temperature (vasoconstriction/vasodilation)

Question 49

TOS causes (4)

Answer 49

1. trauma 2. pregnancy 3. anatomical defects 4. re,petitive injuries