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Vascular Chapter 10
Terms and facts for Vascular Ultrasound.
42
Anatomy
Professional
06/18/2012

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Term
Purpose of Arterial Physologic Testing-LE
Definition
1.Evidence of arterial occlusive disease/PAD. 2.Is it responsible for symptoms. 3.Arterial disease vs. neurospinal. 4.If disease, how severe. 5.Assess increase/decrease in serial follow-up.
Term
Types of Indirect Physiologic Tests
Definition
Pressure assessment (ABI,Segmental), Plethysmography (PVR,PPG), Doppler Waveform analysis. Exercise Stress Test.
Term
Hx Questions for PAD
Definition
Pain when walk? Both? Which is worse? Where in the leg: Calf(SFA/POP),Thigh(PFA),Buttock or Hip(Iliacs)? Pain progressive, stop you from walking? How many blocks can walk? Does pain leave w/rest? Bypass graft/arterial operation? Smoker? Diabetes Mellitus/Insulin? CVA/TIA/MI?
Term
Palpation of Limb Pulses
Definition
0=no pulse
1=weak pulse
2=normal pulse
3=very strong pulse or aneurysmal pulse
Can be taken in the groin(EIA/CFA), POP, Ankle(DPA/PTA).
Term
Physical Signs of Disease
Definition
Pallor,Pain,Paresis,Pulselessness
Coldness
Dependant Rubor
Cyanotic Toes
Ulceration
Non-healing Wound
Term
Claudication
Definition
Progressive pain with exercise in the calf,thigh,buttock or hip. relieved by rest.
Term
Segmental Pressure Principle
Definition
In a normal individual in a supine position, ankle systolic pressure is ≥
brachial pressure. Should be in a warm room in basal state.
Term
BP Cuff Size
Definition
Bladder should be 20% wider than limb diameter.
Thigh=18cm
Arms/Calf/Ankle=10 or 12cm
Metatarsal(Child Sz)=9cm
Digit=2 or 2.5cm
12cm cuffs on Thigh in 4-cuff method.
Term
Steps of Segmental Limb Pressures Test
Definition
1.Patient Prep.
2.Cuff Application.
3.Obtain bilateral arm systolic pressures & compare.
4. ABI
5.Segmental Pressures.
Term
Doppler Pressure Sites for ABI/Segmentals
Definition
Dorsalis Pedis; Easy to compress,hard to find. Extension of Ant. Tibs.
Posterior Tibial; Harder to compress, easier to find.
Term
Photo-Plethysmography (PPG)
Definition
Digit pressure/waveform aquisition w/transmitted infrared light. Reflected light for cutaneous flow. Pros: bilateral capability, convenient,less skill. Cons: ambient light interference, no audible pulse, not good for severe disease.
Term
Ankle/Brachial Index (ABI)
Definition
Bilateral Ankle Pressures divided by the higher brachial pressure. Highest ankle pressure is used for reported ABI.
Term
Segmental Pressure Cuff Inflation
Definition
Inflate the cuff 20mmHg above systolic pressure (Doppler Sound disappears). High thigh cuff in 4-cuff method is inflated 40mmHg above arm pressure.
Term
3- Cuff Method
Definition
18cm wide cuff on thigh. Normal Thigh Pressure=Brachial Pressure.
Term
4-Cuff Method
Definition
2 12cm thigh cuffs. "Normal"(high-thigh cuff artifact) high-thigh
pressure is 20-30mmHg>Brachial Pressure. Can differentiate Aortoilliac vs SFA disease.
Term
Toe/Brachial Index (TBI)
Definition
Normal > 0.75
Abnormal < 0.66
Good for small vessel disease & diabetic patients w/calcified, incompressible vessels.
Term
Resting ABI Values
Definition
> 1.0=Normal(usually)
> 0.90=Normal(sometimes abnormal)
<0.90=Abnormal
<0.8=Probable Claudication
<0.5=Multi-level disease or long occlussion.
<0.3=Ischemic Rest Pain.
Term
ABI Value Exceptions
Definition
Brachial Systolic Pressure <100mmHg or > 200mmHg. Ankle pressure may be 25% lower than brachial and be normal.
Term
Segmental Limb Pressure Interpretation
Tips
Definition
1.Look @ ABI first.
2.Confirm ankle waveforms & pressures match. Normal=Normal/Abnormal=Abnormal.
3.Determine Disease location & thigh pressures.
4.Determine multilevel vs. single level disease.
4. Determine severity & if related to symptoms.
Term
Segmental Limb Pressure Interpretation
Definition
Compare to contralateral limb. Compare to adjacent segments. Compare to brachial pressure. ≥ 30mmHg pressure gradient is significant(>60%) stenosis, in the presence of an abnormal ABI.
Term
High-Thigh Pressure Stats for A-I Disease
Definition
Normal thigh pressure ≥ 20mmHg above brachial pressure.
Negative Predictive Value: 100%
Positive Predictive Value: 42%
Term
Pressure Limitation: Calcified Arteries
Definition
In: diabetics,chronic steroid therapy, renal dialysis patients.
Clues: ABI>1.30, unobtainable pressures,
high pressures distally compared to proximal pressures.
Term
Pressure Advantages
Definition
Quantitative information on limb perfusion. Easy to do. Substantial clinical validation.
Term
Pulse Volume Recording (PVR)
Definition
Aka: Volume Pulse Recording. Air (pneumo) plethysmography. Limb volume changes w/systole, air is displaced in a cuff and change is recorded. Cuff inflated to 60 +-5.If gain is too low can make a normal waveform abnormal looking.
Term
Normal PVR Waveform
Definition
Has a sharp upslope & a prominent reflected wave,dicrotic notch, in late systole/early diastole.
Term
PVR Waveform with Mild Disease
Definition
The waveform will broaden & reflected wave will disappear. Slight loss of amplitude.
Term
PVR Waveform with Moderate Disease
Definition
Waveform has a rounded peak,no reflected wave & a pronounced decrease in amplitude.
Term
PVR Waveform with Severe Disease
Definition
PVR is low amplitude, almost flatline.
Term
PVR Limitations
Definition
Tremor-motion. Distal disease with proximal occulusion. Subjective.
Atrial Fib. distortation.
Term
PVR Advantages
Definition
Easy to learn. Assessment of global limb perfusion. Metatarsal & toe evaluation. Unaffected by calcified arteries.
Term
CW Doppler Sites
Definition
CFA,SFA,POP,PTA(at Medial Malleolus) & DPA(Dorsalis Pedis).
Term
CW Doppler Waveform Analysis
Definition
Warm room & basal state. 4 or 8 MHz Cw Doppler. 45-60 degree angle. Clean waveforms. Use: Analog,zero-crossing detector or FFT color spectrum analyzer.
Term
CW Doppler Waveform Interpretation
Definition
Subjective assessment. Look for: loss of triphasic waveform, dampening of amplitude, slow upstroke.
Term
CW Doppler Waveform Limitations
Definition
1.Junk signals; obesity,scar tissue, occluded artery.
2.Venous Interference; averaged signal.
3.Requires alot of skill.
Term
Exercise Stress Testing Purpose
Definition
1.Differentiate true vascular claudication from pseudo-cladication.
2.Differentiate borderline normal from abnormal. 3.In patients w/combined neuropathy & vascular disease, determine which is limiting walking.
Term
When to do Exercise Stress Testing
Definition
Intermittent claudicators.
ABI 0.85-0.4. Resting study is normal but patient has claudication. DO NOT do if SX @ rest and resting study is normal.
Term
Exercise Stress Test
Definition
Treadmill; 1.5-2mph, 5-10% grade, 5 min. walk time, take post exercise ankle pressures ASAP.
Term
Contraindications for Exercise Test
Definition
Questionable cardiac status,resting ischemia (ABI<0.3),ischemic ulceration, trouble walking, SX @ rest and resting study is normal. Can use toe raises or PORH.
Term
Claudication Criteria; Exercise Test
Definition
Post exercise ankle pressure of 60mmHg or less confirms a vascular etiology.
Term
Post Occlusive Reactive Hyperemia (PORH)
Definition
Occlude distal thigh @ 20mmHg above limb pressure for 3 min. Very painful.
Cannot determine vascular vs pseudo-cladication.
Term
Toe Raises
Definition
Substitue for PORH. 1 min then post exercise pressures. Cannot determine vascular vs pseudo-cladication.
Term
Physologic Testing Limitations
Definition
Detects only hemodynamically significant disease(>60% stenosis).
Usually cannot determine stenosis from occlusion. Region but not site of disease.
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