Week 8: Lower Extremity Arterial Scanning Flashcards
Anatomy: Aorta
Abdominal aorta tapers distally and ends at the _____ arteries
bifurcation of the iliac
Common iliac artery begins at the ____ & ends at the bifurcation into the _____ arteries
aortic bifurcation
internal and external
Common femoral artery begins at the 1 & ends at the bifurcation into the superficial and deep femoral arteries at about the level of the __2__.
- inguinal ligament
- saphenofemoral junction (SFJ)
Name the blood vessels 1-12
5 Abdominal aorta
6 Common iliac artery
9 External iliac artery
10 Internal iliac artery
4 Common femoral artery
12 Deep femoral artery
1 Superficial femoral artery
11 Popliteal artery
2 Tibioperoneal artery
8 Anterior tibial artery
3 Peroneal artery
7 Posterior tibial artery
Superficial Femoral Artery:
* Begins at the ____
* Courses through the adductor canal in the mid-thigh
* Ends at the ____ in the distal thigh
common femoral bifurcation
adductor hiatus
*note: The adductor hiatus (AH) can be described as an opening in the aponeurotic distal attachment of adductor magnus muscle, which transmits the femoral artery and vein from the adductor canal in the thigh to the popliteal fossa
Popliteal Artery:
* Begins at the ____
* Ends at the bifurcation into the
____ and ____
adductor hiatus
anterior tibial & tibioperoneal trunk arteries
Posterior Tibial Artery:
- Begins at the ____
- Courses down the medial calf,
posterior to the medial malleolus - Ends distal to the ____
tibioperoneal bifurcation
medial malleolus
Peroneal Artery:
* Begins at the____
* Courses near the posterior aspect of the fibula
* Ends near the ____
tibioperoneal trunk bifurcation
lateral malleolus
Anterior Tibial Artery:
* Begins at the ____
* Courses between the tibia and fibula
in the anterior lower leg
* Ends at the bend of the ankle and foot
* *Gives rise to the ____
popliteal bifurcation
dorsalis pedis artery
Dorsalis Pedis Artery:
* Begins at the end of the foot (distal anterior tibial artery)
* Ends halfway down the dorsum of the foot as it bifurcates into the deep plantar and arcuate arteries
Reasons to Perform Lower Extremity Arterial Studies (6)
- Chronic atherosclerotic obstructive disease
- Acute arterial occlusion
- Hematoma
- Pseudoaneurysm
- Arteriovenous fistula
- Bypass graft surveillance
Clinical History for reasons to Perform Lower Extremity Arterial Studies
diabetes
Diabetes
-High risk factor for arterial disease and non-healing ulcers (feet)
-More prevalent disease of the ____ and ____ vessels
-Tunica media calcifies causing the arterial walls to be echogenic
-Higher risk for amputation
distal popliteal, tibial
Risk factors for atherosclerosis: (4)
- hyperlipidemia - due to high cholesterol or genetic, diet, and lack of exercise
- smoking
- age
- male gender
When acute arterial occlusion is suspected look for the Five P’s:
- Pain
- Pallor (white)
- Pulselessness (cannot find pulse)
- Paresthesis (numbness)
- Paralysis (cannot move)
What is claudication?
limping.
a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.
Claudication
* Pain in muscles that occurs with ____(due to the demand of additional blood flow required by the muscles during exercise)
* Patients with claudication typically have ____
* Sometimes called **intermittent claudication **because pain is only with exercise
* True claudication is ____ and ____
* Symptoms are ____ (ex: walk two blocks and onset of pain occurs)
exercise
chronic atherosclerotic disease
predictable & reliable
consistent
“Today its okay but last week I couldn’t walk too far”
-Can be caused from a neurological issue (back injury, disk trauma), or musculoskeletal
This conditon is called:
pseudoclaudication
Pain
-Calf Pain: look for disease of the ____ or ____ artery
-Thigh Pain: look for disease of the ____ or ____ artery
-Buttock Pain: look for disease of ____ disease
*The arterial obstruction will be ____to the site of symptoms/pain
- trifurcation, femoral
- external iliac, common femoral
- aortoiliac
- proximal
Rest Pain
-____ etiology
-Common complaint is pain at night while sleeping that is only relieved by dangling legs over the side of the bed (due to gravity pulling blood down- hydrostatic pressure)
-Pain in foot, heel, toes, but NOT the ____
-Indicative of severe disease
-Can progress into gangrene due to absence of flow
Ischemic
calf
Visual Examination of the extremeties (5)
- color
- temperature
- ulceration: Distal ankle and feet
-If severe and non-healing, gangrene can occur and lead to amputation - hair loss: look for hairloss on top of toes
- toenails: thickened toenails are more consistent with disease
Look at the extremities
Color
1. ____: pale color
2. ____: darkish reddish due to damaged dilater vessels (acute emboli)
3. ____: lack of oxygen causing a bluish discoloration
Temperature
-Cold extremities is more indicative of lack of blood flow (decreased circulation)
-Compare temperature of both extremities
- Pallor
- Rubor
- Cyanosis
Palpate over pressure points
-Common femoral artery in the groin
-Popliteal artery in the popliteal fossa
-Posterior tibial artery at the medial ankle
-Dorsalis Pedis on the foot
Vascular Testing: Arterial
You want the examination room to be warm
–Too cold will cause vasoconstriction
-Can falsely create high resistive waveforms leading to a false- negative result or ambiguous results
Allow patient to rest after walking from waiting area
-Perform exam at the resting state
Direct vs. Indirect Testing
** Direct**
* Duplex scanning
allows quantification and specific location
* Creates sonographic images, spectral Doppler analysis and use of** color Doppler **or Power imaging
Indirect
Reveals physiological disease, but nonspecific to quantization and location
* Continuous wave Doppler and pressure cuffs
* No sonographic images
What is the Patient Positioning: Direct ?
-
Supine
*Reverse Trendelenburg position
-Pools the blood in the veins and makes the adjacent arteries easier to identify
most commonly used TDR for thid study?
linear array
Direct Testing
Duplex Imaging:
* Provides more specific location(s) and severity of disease
* ____ are more valuable than transverse images due to the
evaluation of the hemodynamic change to distinguish disease
* Arteries from the ____ artery are most commonly evaluated
-Some facilities include the** aorta** and **iliac arteries **
-Some facilities include the calf arteries
* Need to follow & understand the concepts of Doppler -Angle placement and < 60 degrees
-Color Doppler is essential & useful
Sagittal images
groin to the distal popliteal
Duplex Technique: CFA
* Want to image as far ____ as possible
* Artery is located lateral to the ____
* Look at real time plaque formation
* Use color and adjust color scale
* Obtain a PW Doppler signal & measure PSV
* Evaluate the shape of the waveform
proximal
CFV
identify the vessels
- CFA: common femoral artery
- CFV: comon femoral vein
- SFJ: sapheno-femoral junction
- CFA
- SFA: superficial femoral artery
- DFA: deep femoral artery or profunda femoral artery
Duplex technique
Move ____:
Look for the **bifurcation of the CFA **into the profunda femoral and superficial femoral artery
-Color Doppler, look for changes
Obtain PSV of the PFA and the proximal SFA at the take off
distally
Continue distally:
- Using color follow the SFA distally looking for areas of increased velocity (mosaic color pattern)
- Take PW Doppler waveforms at
mid and distal SFA and any areas of suspected stenosis
If area(s) of stenosis is seen, always take a pre and post stenotic PW Doppler sample
!!arteries are _____ to the vein, until you reach the popliteal artery!
anterior
Name the vessels
- SFA: superior femoral artery
- SFV: superior femoral vein
Duplex technique
* Trace the popliteal artery from proximal to distal
* Obtain Doppler waveforms
!!IMPORTANT: Popliteal artery appears ____ to the popliteal vein when using a posterior scanning approach!
posterior
name the vessel
- PV: popliteal vein
- PA: popliteal artery
Duplex Technique
Calf Arteries:
Duplex depends on facility
!!Important: PTA/Peroneal arteries are accompanied by____
2 veins
1. PTA: posterior tibial artery
2. peroneal artery
Duplex Scanning Considerations
In events of total occlusion there is loss of color flow:
-decrease color scale to rule out slow “string” flow
-document on color
-document absence of waveform with PW Doppler
-look for the area of reconstitution
Duplex Scanning Considerations
- Prefer to do a bilateral exam to compare side to side
- Some facilities will perform targeted exams to look at the site of abnormality
- Some facilities will duplex **peroneal to the ankle **for potential
grafting patency
Interpretation: Normal
Normal peripheral arteries exhibit __1__ flow
-We want __2__ waveforms
-As patient’s age, we may see __3___ waveforms
-If you see a monophasic waveform, look __4___
-If you see a “thumping” waveform (no diastole), look _5___
!!! If disease is seen proximal on both legs, look at the __6___
- high resistive
- triphasic
- biphasic
- proximal
- distal
- aorta
Indirect testing
What are the 3 components?
- Continuous wave (CW) Doppler testing
- Pulse Volume Recordings (PVR’s)
- Segmental pressures
Indirect testing
What are the 3 omponents?
and the patient’s position?
- Continuous wave (CW) Doppler testing
- Pulse Volume Recordings (PVR’s)
- Segmental pressures
supine
What is this?
Pencil probe that only performes Doppler (no imaging)
*Want to angle the probe to provide a 60 - degree angle with the vessel
* Listening to the signal provides the best quality and accuracy
* Slow angulations of the probe to tweak the signal
Prefer to perform first to provide insight on the physiological information on the results of the exam
* CW does not provide range resolution so venous signals can interfere in the path of the beam creating an ambiguous waveform
-Have patient take a deep breath in and hold to cease venous flow
CW Doppler
Perform CW Doppler at the following sites: (5)
- CFA
- SFA
- POP artery
- posterior tibial artery
- dorsalis pedis
*Can use peroneal artery if PT and DP are absent
**CW Doppler Pitfalls:
**
1. Improper probe position
2. Incorrect angle - Not 60 degrees or less
3. Excessive pressure on probe - Especially distal vessels (ankle & foot)
4. Insufficient rest prior to onset of exam - Increases vasodilation
5. Inadequate amount of gel
interpretation
triphasic = normal
Interpretation
biphasic
- can be normal in elders due to dthe stiffness of the vessels
- seen usually proximal to a stenosis
Interpretation
monophasic = abnormal
- usually seen distal to a stenosis
- tardus parvus
