RVT
Hyperostosis
Excessive or abnormal thickening or growth of bone tissue.
gold standard NPV
TN/ FN + TN
popliteal vein becomes the femoral vein when it passes through
adductor hiatus in the lower thigh
arteriovenous malformations with a TCD exam has reduced flow in
adjacent arteries
during volume plethysmography systole appears as
air pressure in cuff increases as arteries expand
unclear whether high blood pressure is a causative factor or enhances the development of
atherosclerotic process
portocaval shunt
attaches the main portal vein at the superior mesenteric vein-splenic vein confluence to the anterior aspect of the IVC
how to determine area of abnormalitity with thoracic outlet syndrome
attenuation or flattening of the waveforms in one or more positions
_____ artery is used to obtain the BP in the upper arm
brachial
axillary artery becomes the
brachial artery
what cause cause ulceration in incompetent valves
breakdown of substances prevents proper tissue nutrition and oxygenation
lytic therapy
breakdown of thrombus
reasons for augmentation
checking to make sure blood is going the right way
perforators of the posterior arch vein
cockett III cockett II cockett I
digit plethysmography and pressure exam for the toe is done in combination with
complete LE arterial limited ABI
peripheral resistance increases the arteries
constrict
blood attenuates light in proportion to its ________
content in tissue
chronic changes of a vein flow characteristic will appear
continuous decreased phasicity no augmentation venous reflux lasting >0.5-1 sec
Flow to a warm extremity (vasodilatation) will have ______ signals
continuous/ steady
Pulsed Doppler
crystals send then receive the reflected ultrasound
collaterals will lead to low resistance ____________
distally
normal lymphatic system
drains excess fluid from tissue
spectral analysis is more common during
duplex evaluation
A normal stented artery may have _____ PSV
elevated
analog
employs a zero crossing frequency meter to display the signals graphically on a strip chart recorder
when performing the valsalva maneuever all venous return is
halted
how to diagnose primary raynauds
history of symptoms for 2 years without progression/evidence of cause
Accuracy
how good a test is
poiseuilles equation helps answer the question
how much fluid moves through a vessel
some complications of coarctation of the aorta
hypertension due to decreased kidney perfusion, LE ischemia
internal iliac artery is also called
hypogastric artery
internal mammary artery also called
internal thoracic artery
tiny ultrasound probe at tip of catheter provides image of vessels from the inside out
intravascular ultrasound
secondary raynauds _____ is constantly present
ischemia
Specific eye symptoms (amaurosis fugax) are suggestive of ___________
ispilateral ICA disease
SSV-popliteal junction
joining of the small saphenous of the politeal vein
vena caval interruption device is a filter placed in IVC (below the renal veins) via
jugular or femoral vein
renal arteries supply blood to the
kidneys, suprarenal glands, ureters
cephalic vein empties
lateral aspect of the arm
volume and photo plethysmography severly abnormal waveform appears as
low amplitude or absent
inferior vena cava drains
lower half of body
greater saphenous vein travels __________ to saphenofemoral junction in the groin (about level of CFA bifurcation)
medially
contraindicated
not recommended under these circumstances
stored energy, expressed in mmHg, major form of energy for circulation of blood
pressure energy (potential/stored)
major types of ablations
radio frequency ablation and laser ablation
TRAM contains
rectus abdominis muscle, sub-q fat, arteries, perforators, overlying skin
when obtaining the p02 number from a transcutaneous oximetry TcP02 exam where are the readings taken?
reference reading done first (upper lateral chest specific sites (toes, BK, AK)
effective calf muscle pump blood moves from
superficial system to deep system
cca branches into
ica and eca
central veins
superior vena cava inferior vena cava portal vein hepatic vein renal vein
endarterectomy
surgical removal of atherosclerotic material, usually includes portion of intimal lining
how is venous photo plethysmography recorded
strip chart recorder
locate the renal arteries in what
transverse
IMA supplies blood to the
transverse and descending colon, rectum
easy way to identify the vertebral arteries is be the vertical shadows running through it
transverse process of the vertebrae
(TRAM) flap stands for
transverse rectus abdominis myocutaneous
chemicals in cigarettes can irritate the endothelial lining of the vessels that can lead to
vasoconstriction
subclavian occlusion results in retrograde flow in ispilateral
vertebral artery
Saphenofemoral Junction (SFJ)
where great saphenous joins CFV
how does claudication resolve
within minutes after exercise
transcutaneous oximetry TcP02 is used for
wound healing and amputation level determination
stenosis should be visible from
2 projections
Paper speed
25 mm/sec
chart paper speed =
25 mm/sec
which cuff method provides a more accurate reading
3 cuff method
IMA arises from the aorta about ______ above bifurcation
3-4 cm
complications with angioplasty occurs in less then
5% of cases
Analog Doppler are not capable of portraying velocities less than what cm/sec?
6
infrapopliteal (deep veins) contain how many valves
7-12 valves
normal renal to aortic ratio
<3.5
Strandness work suggests that an ABI of ____ represents single segment disease and ___ suggests multiple lesions.
>.5 <.5
best way to asses patient for brain death
TCD
gold standard PPV
TP/ TP + FP
how is the digit plethysmography and pressure fingers with cold stress performed
after resting hands are immersed in ice cold water for 3 minutes waveforms and pressures are obtained immediatley after and then after 5 minutes
misinterpretation of the doppler signal due to limitations of equipment being used can result in
aliasing
residual volume fraction (RVF) is equivalent to
ambulatory venous pressure in mmHg
spectral analysis is free of
analog recording drawbacks
ICA originates from
CCA
Duplex scanning
Combination of real-time B-mode imaging (grey scale) and Doppler spectral analysis.
angioplasty unlike arteriography used what kind of catheter
balloon tipped
example of DC
batteries
energy expanded as heat such as eddys and vortices work against
blood viscosity
aneurysms can be palpated and described as
bounding
example of flow separation areas with little flow
bypass graft anastamosis or valve cusp site
skin with elevation appears
cadaveric pallor
most common site for atherosclerosis
carotid bifurcation, vessel origins, infra-renal aorta-iliac system, CFA bifurcation, SFA at the adductor canal, trifurcation region
highly vascular structure that develops between the ICA and ECA
carotid body tumor (CBT)
improper contact with the skin surface for photo plethysmography
cause poor results
Median arcuate ligament of diaphragm compresses
celiac artery
abdominal aorta branches
celiac, SMA, renal arteries, IMA
liver transplant rejection is a _____ process
cellular
where is the fastest moving flow located with laminar flow
center
where is the best doppler sample taken
center stream parallel to vessel wall
pressure measured at all levels =
circulatory pressure
hydrostatic pressure is added to the exsisting __________ and is related to ________
circulatory pressure position
occlusion may have evidence of __________ and ECA may exhibit ___________
collateralization high flow in end diastole
claudication
cramping in the leg caused by obstructed arteries (usually the pain occurs during walking or exercise)
quantitative way of evaluating for reflux uses a
cuff inflation technique with duplex scanning, patient standing and bearing weight on contralateral leg
what determines the reflection in the PPG
cutaneous blood flow
each cardiac contraction _____ the arteries
distends
transmural pressure is also known as
distention pressure
calcified vessels in LE & UE can render falsely elevated
doppler pressures
what may be placed around IVC during abdominal surgery to decrease risk of PE
external caval clip
the _________ veins carry about 2/3 of the blood in the body
extra pulmonary veins
aphasia
inability to speak
Claudication results from
inadequate blood supply to muscle
post-prandial of the SMA PSV? EDV? loss of flow reversal?
increase increase yes
valsalva maneuver in venous system causes intra-thoracic and intra-abdominal pressure to
increase significantly
waveform for alaising
flat - crew cut appearance
in a normal artery elevated PSV are abnormal and suggest
hemodynamically significant diameter reduction
bruit is frequently associated with
hemodynamically significant lesion
what causes break down of stagnant RBC and causes a brawny discoloration in incompetent valves
hemosiderin
acute DVT and/or PE anticoagulent treatments
heparin- loading dose followed by continuous intravenous infusion for 5-10 days coumadin- oral anticoagulation started nearing end of heparinization prescribed for 3-6 months
flow is variable in what abdominal vein
hepatic vein
primary site of obstruction for budd-chiari syndrome
hepatic veins, sinusoids, IVC
what kind of flow is seen with hepatic veins
hepato-fugal
portal hypertension can result in _______ flow in the portal vein and ________ portal venous pressure that impedes (delays) blood flow into the liver
hepato-fugal increase
flow of a pulsatile nature
high resistance flow
if arteries arent audible inflate the pressure cuffs in the legs 20-30 mmHg higher than the
highest brachial pressure
lower extremity exam should be performed with _______ transducer
7 - 5 MHz
ABI with rest pain (severe arterial disease)
<0.5
Abnormal penile/brachial index
<0.65
normal dorsal vein velocities in a doppler imaging study of the penis
<3 cm/sec
a decrease in ABI of __________ is considered abnormal
> 0.15
normal EDR
> 0.2
abnormal RI
> 0.8
normal ABI
> 1.0
Abnormal acceleration time
> 100 m/sec
patients with a subclavian steal may have a blood pressure diffrence of
> 15 - 20 mmHg decreased pulses in affected arm
normal venous photo plethysmography VRT =
> 20 seconds without tourniquet
reynolds number when laminar flow tends to be disturbed
> 2000 (unitless number)
2:1 ratio =
> 50% diameter reduction
abnormal renal aortic ratio
>3.5
DPA penetrates the sole of the foot and unites to form ______ to complete the ______
lateral plantar artery complete plantar arch
radial artery courses along
lateral side of the forearm into the hand
peroneal artery supplies blood to the
lateral side of the leg/foot
laminar flow consists of
layers of fluid particles moving against one another
left common iliac vein passes under the
left common iliac artery
arterial ulcers will have _______ bleeding
little
purpose for duplex/color imaging of the carotid
localize lesion in the extra-cranial arteries differentiate stenosis from occlusion document progression of disease identify chracteristics evaluate pulsatile mass
duplex/color flow UE arteries imaging capabilities
localize stenosis/occlusion evaluate degree of stenosis determine presence/absence of aneurysm detect AVF Detect unusual abnormalities
atheromatous plaque
localized accumulation of lipid containing material (atheroma), smooth muscle cells, collagen, fibrin and platelets
aneurysm
localized dilation of a blood vessel due to congenital defects or weakness of the wall (trauma, infection, atherosclerosis)
thoracic outlet syndome
neurovascular bundle compression by shoulder structures (cervical rib, clavicle, scalene muscle) occurs in certain arm positions
post-prandial of the celiac artery PSV? EDV? loss of flow reversal?
no change no change does not apply
occlusion with arteriography appears as
no filling seen with collaterals most likely present
Spontaneous flow
no flow pattern, random flow, not phasic not continuous
for upper extremity velocities there is _______ criteria, rather follow up studies provide comparison on the same patient
no standardized
distal arterial flow to AVF
normal triphasic
viscosity decreases _______ increases
velocity
ineffective calf muscle pump results in
venous pooling and ambulatory venous hypertension
air plethysmography uses a pneumatic cuff connected to a pressure transducer so that
volume changes amplified and converted to analog display
radius of the vessel is directly proportional to
volume flow
hemodynamically significant stenosis causes a notable reduction in
volume flow and pressure
stationary layer remains at the
wall
common iliac arteries carry blood to the
pelvis, abdominal wall and lower limbs
poor arterial flow to the LE due to proximal obstruction may affect
penile arterial inflow
acute thrombosis is suspected when
peripheral veins not completely compressible being filled with very low level echoes vessel dilated
PICC line stands for
peripherally inserted central catheter
pallor can occur due to
phlegmasia alba dolens
venous ulcers appear
shallow, irregular shape
MRA can overestimate stenosis due to
slow flow or turbulence
augmentation creates _______ flow
spontaneous
typical venous flow patterns
spontaneous phasic augment with distal compression augment with proximal release
laminar flow is also considered
stable flow
example of venous stasis
superior vena cava syndrome
most common findings of acute DVT
swelling, pain, redness, warmth
portal hypertension
the elevation of venous pressure results from obstruction of blood flow
spectral analysis is displayed as
time displayed on the horizontal axis (x) frequency shifts displayed on the vertical axis (Y)
how long does it take for pseudo aneurysm to thrombose
time varies
unilateral paresthesia
tingling or numbness to ONE side of the body.
three acoustic windows used for TCD exam
transorbital transtemporal transforaminal/ suboccipital
allograft
transplantation of healthy tissue from one person to another person; also called homograft
___________ approach of TCD imaging can be limited by adequate penetration of temporal bone from hyperstosis
transtemporal
Tardus parvus waveform is seen
Downstream from a stenosis
carotid body tumor is usually fed by
ECA
intra-plaque hemorrhage
Evident on B-mode as a sonolucent area within plaque
flow is directly related to what in pousilles law combined with resistance equation
P and r^4
compartment syndrome
Pressure constricts the structures within a compartment resulting in damaged blood vessels
fatty streak
Thin layer of lipid material on intimal layer
internal mammary artery arises off
arch of subclavian artery
Abnormal "jet" (elevated velocities) may be isolated to:
area of stenosis or entering or leaving stenosis
axillary is evaluated in what positions
arm raised, pledge position, probe in armpit
basilic vein can be harvested for
arterial bypass conduit
treatment to decrease thromboses
aspirin
capabilities of doppler segmental pressures (LE) and (UE)
asses presence/severity of arterial disease
capabilities of color flow in the pelvic and abdominal veins
assess portocaval shunts eval liver diseases eval patency of IVC interruption device idenitfy thrombosis document elevated systemic venous pressure
symptoms of subclavian occlusion
asymptomatic claudaction rare
cw exam is based on ________ venous signals
audible
essential to compare flow characteritics ________ and proximal-distal segements of ______________
bilaterally ispilateral vessel
many consider ______ to be the most reliable method for rejection diagnosis
biopsy
in rare cases some patients have ______ flow without evidence of disease
biphasic
pressure difference is important to maintain
blood flow
inflow represents
blood flowing into the lower extremeties
Buerger's disease
blood vessels become inflamed, swell and can become blocked with blood clots related to smoking
primary example of embolism of the digits
blue toe syndrome
cyanosis
bluish discoloration of the skin
edema
body tissue contains an excessive amount of fluid
surgical treatment for a subclavian steal may include
bypass graft or endarterectomy
duplex/color imaging LE arteries can be used to follow up
bypass grafts
soleal sinus is a major part of the
calf muscle pump
venous photoplethysmography (PPG) cannot be ________ as with venous air plethysmography (APG)
calibrated volumetrically
flow information greater then 1/2 the PRF
cannot be displayed
main disadvantage of CW
cannot pinpoint where along the line the velocity is coming from
a place where nutrients and waste products are exchanged between the tissue and blood
capillaries
arteries transport gases, nutrients and other essential substances to the
capillaries
if AVF is close to heart it causes potential risk
cardiac failure
functional (intermittent) obstructive disease show abnormal findings after
cold stimulation
doppler velocities typically recorded bilaterally in the lower extremities
common femoral artery superficial femoral artery popliteal posterior tibial (medial malleolus) dorsalis pedis peroneal (lateral malleolus)
volume plethosmography and pressures are
complementary
paired brachial veins formed by
confluence of radial and ulnar veins
superior vena cava vein formed by
confluence of right and left innominate veins
Innominate or Brachiocephalic Vein formed by
confluence of subclavian vein and internal jugular vein
paired posterior tibial veins formed by
confluence of venules
paired radial veins formed by
confluence of venules
Proximal to arch, the first branches of Ascending Aorta are
coronary arteries
systemic hypertension is associated with a greater incidence of
coronary atherosclerosis
PPG detects
cutaneous blood flow rather then truly measuring volume change
Subclavian aneurysms are often associated with ____ to the digits.
embolization
amount of floe depends on
energy difference any resistence which opooses such movement
______ is needed to move flow from one point to another
energy gradient
Eddy currents , Turbulence , Vortices cause
energy loss through inertia
acceleration causes increased
energy losses
purpose of the fistula or graft for hemodialysis is to
enlarge the vein to allow reoccurent needle sampling for dialysis otherwise vein will collapse
troubleshooting- venous plethysmography- absent deflections or grossly irregular tracings?
ensure equipment is on DC mode and on PPG setting
Renin
enzyme that converts angiotensinogen to angiotensin
hydrostatic pressure
equivalent to the weight of a column of blood pressing against the vessels of the body; use heart as a reference point
ways to ensure patient safety
escorted to/from examination room assisted on/off exam table if patient is on stretcher put side rails up before and after study completed
Allen test
evaluate the patency of the palmer arch
sources of falso positive CW studies
extrinsic compression peripheral arterial disease- decreased venous filling chronic obstructive pulmonary disease- elevated central venous pressure improper doppler angle or probe pressure
spectral analysis displays true
frequency/ velocity shifts
location of the brachial veins vary
from antecubital fossa to axilla
paired anterior tibial veins empty
front of leg
between incident pulses hydraulis reflections travel back up the vessel from the periphery producing flow reversals in vascular compartment
high resistance flow
with the 3 cuff technique can not differentiate between
high thigh and above the knee
where are measurements obtained of the GSV or SSV for preopperatively venous mapping
high, mid, distal thigh, knee, BK, prox, mid and distal calf, ankle
reason patient position is so crucial with lower extremity doppler pressure exams
hydrostatic pressure cannot affect the BP measurements
exhalation in the venous system causes ________ in intra-thoracic pressure and ________ in blood flow from UE
increase decrease
________ and _________ varies with stent type
insertion and deployment
_________ required for sensor placement
intact skin
common iliac vein formed by confluence of
internal and external iliac veins
Gaitor zone
just below the knee to the ankle
paired peroneal veins empties
lateral leg
brownish discoloration can be seen with venous stasis usually occurs
lower leg to ankle area
Compression of the left common iliac vein by the right common iliac artery can lead to left sided DVT
may thurner syndrome
first part of the doppler penile exam the cavernous arteries are _________ and _________, _________, ________ are obtained
measured A/P diameter in TRV PSV, EDV, dorsal velocities
arterial dissection
media is weakened and intima develops a tear through which blood leaks into the media (false lumen)
evaluate the PTV along the _______ surface of the calf
medial
paired ulnar veins empty
medial hand and forearm
proximal occlusion of the subclavian artery will make the waveform appear
monophasic
pre stenotic doppler spectra waveform appears
monophasic and dampened
vasospasm
narrowing of the arteries caused by persistant contraction of the blood vessels
with compartment syndrome any swelling may cause compression on the tibial arteries resulting in
necrosis of the muscles causing severe pain, tenderness, foot drop and neurological changes
tissue loss due to chronic occlusive disease causes
necrosis or death of tissue
body part above heart (raising arm above head) results in what kind of HP
negative HP measured pressure is lower then circulatory pressure
duplex/color imaging of the kidney can help evaluate for
nephrosclerotic disease and transplants
if retrograde flow is present in augmentation flow will be seen
normal below baseline, augment, flow above baseline
acute arterial occlusion symptoms include the 6 P's
pain, pallor, pulselessness, parethesia (prickling), paralysis, polar
pallor
paleness
raynauds phenomenon can cause changes in skin color such as
pallor (whiteness), cyanosis (bluish), rubor (dark red)
hemiplegia
paralysis of one side of the body
enhance services of computerization
patient scheduling report generation storage of data
first step in performing air plethysmography
patient supine, cuff applied to lower leg, air injected to 6 mmHg pressure level, manual calibration completed
what to document after exam is performed for digit plethysmography finger cold stress test
patient symptoms, skin color observation and other pertinent findings
CT provides limited application in ________ due to smaller vessels
peripheral arterial disease
important to miantain a warm environment for the patient in order to permit warming which causes ________
peripheral dilation
retrograde flow results from a
pressure gradient
prophylaxis
prevention of disease
acute thrombosis usually occurs due to
trauma
triphasic flow
rapid upslope sharp peak rapid down stroke flow reversal resumption of forward flow
Types of aneurysms
true (fusiform, saccular) false (thrombus present)
Pulse Plethysmograph
refers to transient changes in the limb volume related to the pulse by pulse acitivity of the left ventricle; the body part expands when arterial inflow exceeds venous outflow
peripheral resistance
resistance of the arteries to blood flow
problems that can arrise with a stent graft
restenosis due to intimal hyperplasia stent migration graft limb compression twisting dislodgement endoleaks
Valves in veins prevent what?
retrograde flow
pressure and waveforms for digit plethysmography fingers without cold stress are obtained
same as toe pressures
what is important to be maintained throughout the volume plethysmography
similar gain setting, if it is different it needs to be noted on the recording paper
<50% drop in ankle pressure ABI with reactive hyperemia is associated with
single level disease
limitations to duplex/color imaging of the abdomen
size of patient bowel gas previous abdominal surgery (scar tissue) shortness of breath and rapid respiration patient in non-fasting state
DC can detect _______ changes in a blood constant
slower
most frequent cause of embolism
small plaque breaks loose and travels distally until it lodges in a small vessel
carotid body
small structure located just above the carotid bifurcation
spectral broadening is evident of
turbulence
phlebectomy
surgical removal of varicose veins
vasoconstriction and vasodilation of blood vessels within the skeletal muscles are influenced by
sympathetic innervation fibers functioning primarily for regulation of body temperature
dampened, weak doppler signals distally, low resistant
tardus parvus
reynolds number predicts when fluid becomes
unstable/disturbed
when is reactive hyperemia ABI obtained
upon release of cuff occlusion
digit plethysmography and pressures of finger without cold stress exam what is initially completed
upper extremity arterial study
abnormal peaked waveforms post finger cold stress for digit plethysmography appear as
upslope is slower then normal sharp notch present reflected wave located high on downslope characteristics of both normal and obstructive
venous pooling
valves in the veins arent working effectively so return to heart from legs is delayed so accumulation of blood in the veins
Neointimal hyperplasia is in response to:
vascular injury/ reconstruction post carotid endarterectomy
quality of digit plethysmography tracings can be greatly affected by
vasoconstriction of arteries before test begins cold, nervous, smoking
viscosity increases _____ decreases
velocity
V =
velocity of flow (moving reflectors)
DC is used for
venous studies
during volume plethysmography after the cuff is inflated arterial flow moves under the cuff and momentary ________ changes in the limb segment occur and are converted into
volume pulsatile pressure changes
Plethysmography measures
volume changes
transmural pressure is the pressure
within the vein versus pressure outside the veinl
what angle is used for TCD exam
zero angle of insonation
best way to image native arteries is with a _________ transducer
5 - 7 MHz linear
renal transplant evaluation uses a ______ transducer
5 MHz
what probe is used for a venous CW exam
5 MHz and held 45-60 degrees to skin surface
organ transplants use what type of transducers?
5 MHz or 3MHz
Definitave diagnostic tools of pulmonary embolism
CTA chest and pulmonary angiography
in-situ vein graft
GSV stays in place Small end is distal Large end is proximal Prior to surgery valves are broken up with special instrument, branches are ligated (GSV attached to femoral artery just prox and distal to go around occlusion)
flow disturbance occurs due to
Interrupted flow stability w/ high velocities & eddy currents
upper extremity arteries
Subclavian, axillary, brachial, radial, ulnar, superficial palmer arch, deep palmer arch and digital arteries
examples of triphasic flow
UE and LE arteries
Augmentation with distal compression may not be evident in what vessels?
UE veins
acute arterial occlusion is considered an emergency situation because
abrupt onset does not provide time for development of collateral channels
______ flow can mistakenly over estimate stenosis
accelerated
fatty streaks are found within vessels in patients of all
ages
why is surgery a risk factor for DVT?
alteration in the endothelial cell function
following cold immersion of the finger cold stress test for digit plethysmography abnormal cold sensitivity is suspected if
amplitude fails to return to normal within 5 minutes
reflected wave
an erect or inverted returning wave that results from some of the energy of the incident wave's pulse being reflected backward
True Aneruysm
an out-pouching of all three layers of a blood vessel; the intima, the media, and the adventitia
Arteriography is primarily a(n) ____ study rather than a functional study.
anatomic
anastomatic sites should be evaluated well for
aneurysm and stenosis
Aspirin
antiplatelet drug that decreases platelet aggregation resulting in decreased thrombotic activity
limitations for penile doppler imaging
anxiety or antagonism (hostility) sensitivity to injectable medication or anticoagulation therapy may prevent use of the injection component duplex needed for velocities
displacement plethysmography
any change in volume of the enclosed part will displace an equal amount of water
abnormal blood vessel appearance in B-mode
any increased echogenicity found within the vessel lumen
Arteries progressively decrease in size from the largest being __ and the smallest being ___
aorta arterioles
arterial dissection typically affects
aorta peripheral arteries
an example of in flow disease is
aorto-iliac disease
TCD can evaluate for intracranial ________ malformations
arteriovenous
strandness and sumner qualitative doppler describe
arteriovenous shunts in the skin of the fingertips that cause flow patterns in hand to be tremendously variable
AV fistula appearance in a color image
artery hepatopetal alias at anastomosis vein hepatofugal (larger)
dialysis access order
artery inflow, anatomosis, venous outflow
hyperlipidemia is closely associated with
atherosclerosis
diabetes carries a risk factor for
atherosclerosis in young people
most common arterial pathology
atherosclerosis obliterans
renal artery stenosis is usually secondary to
atherosclerosis or fibromuscular dysplasia
the majority of abdominal aortic aneurysms are
atherosclerotic and infrarenal
the systolic pressure of each measurement is recorded at which the first _________ returns
audible doppler arterial signal
proximal release augmentation
augment proximal to probe to push flow backwards to check for reflux
Ability of most vascular beds to maintain constant level of blood flow over a wide range of perfusion pressures
autoregulation
congenital venous disease
avalvular (valveless veins) arteriovenous malformations syndromes
color doppler assigns
average frequencies and phases of moving blood
secondary raynauds may be the manifestation of
buergers disease
preopperative vein mapping for the upper extremities map which veins
cephalic and basilic
Doppler Color Flow Imaging
doppler information is displayed on image after evaluated for phase (direction toward or away from the trasnducer) frequency content (hue or shade of the color)
the audible and wave form qualities are observed, documented and combined with
doppler segmental pressures
Ejection Fraction (EF) is calculates using
ejection volume (EV) and functional venous volume (VV)
external to interal flow
example opthalmic artery
primary raynauds has a ______ prognosis
excellent
decision to operate on arteries depends on
extent of disease and primarily the patients symptoms
possible position for CW venous exam to diminish extrinsic compression on IVC with pregnancy, ascites, tumor formation
extreme side lying position
Systole
forward flow throughout the periphery (fluid acceleration)
lower resistence =
high flow rate
vessel motion of an occluded artery is
horizontal or piston-like
when recording venous reflux make note
how long reflux lasts (how long above baseline)
interpretation of arteriography is based on
how much of an artery does not fill with blood containing contrast agent extent and location of filling defect is recorded
Negative predictive value
how often negative study is correct
Positive Predictive Value (PPV)
how often positive study is correct
color doppler frequencies
hue or brightness of color
abnormal calculations of EDR and RI indicate
increase in distal resistance
normal ABI post exercise will be
increased
emboli can originate _______ or _______ the body
inside outside
portal hypertension related to
chronic liver disease, hepatitis C, cirrhosis
false negative CW studies
collateral development presence of bifed system (multiple deep veins)
Waveforms may not be altered with good
collateralization
physical exam that consists of palpations of what arteries
common carotid, superficial temporal, subclavian, axillary
sublavian vein formed by
confluence of axillary vein and cephalic vein
how do AVF form?
congenital or traumatic
in an AV fistula large blood volumes shunted from artery to lower resistant venous circulation it can increase venous return resulting in
congestive heart failure
treatments for thoracic outlet syndrome
conservative shoulder exercise surgical treatment done by rib resection with or without scalene splitting
If BP rises, resistance vessels______
constrict
examine renal artery area to look for
secondary or accessory renal arteries
with analog most equipment does a __________ when the system is activated
self calibration
digit plethysmography and pressures of the toes is recorded with _________ for _________
self calibration all toes
what is necessary for recording a vasospam
serial recording
arterial ulcers will have _______ pain
severe
contrast venography may be contrindicated in patients with
severe PAD secondary to risk of extravasation and patients allergies to iodine
any type of digit arterial occlusion results in __________ pressure
severely reduced
normal waveforms post finger cold stress test for digit plethysmography
sharp upstroke during peak systole pro-longed downstroke with notch (reflected wave) approximatley half way down amplitude greater with tow tracings
significant decrease in MCA flow velocities during cross sectional clamping of a vessel may indicate a need for
shunting
phased array
small footprint with fan or sector shaped image
preoperative arterial mapping of the radial artery is to determine
suitability for use as a graft for coronary artery bypass
identification of flow abnormalities within the circle of willis may warrant change in
surgical technique
acute live transplant rejection causes
liver dysfunction
bruits have ______ frequency
low
high resistance =
low flow rate
electrical coupling
method to increase gain and display signal
arteriography allows you to detect
normal anatomy abnormal filling defect, absent vessel, aberrant (not normal) anatomy percent stenosis calculation
CW doppler limitation is it can mistakenly show evidence of partial or well collateralized thrombosis in a
normal flow pattern
Frontal Artery arises from
ophthalmic artery
which branch of the ICA originates near the carotid siphon and is a significant curve of ICA
opthalmic artery
branches of the ICA intracranial
opthalmic artery posterior communicating artery
transorbital approach allows for the evaluation of
opthalmic artery and carotid siphon
plug flow is usually seen at the _____ of the vessel
origin
always compare asymptomatic side with _________ side
symptomatic
patient with popliteal artery entrapment syndrome present with
symptomatic arterial occlusion or intermittent claudication
paralysis
temporary or permanent loss of motor control
Iliofemoral venous thrombectomy
performed for impending (about to happen) limb loss if thrombolytic therapy does not dissolve clot
HP =
pgh + circulatory pressure p= specific gravity of blood g= acceleration due to gravity h= distance from the heart
cyanosis can be caused by
phlegmasia cerulea dolens
movement of the fluid is dependent on
physical properties of the fluid and what its moving through
main advantage of CW
pick up very high velocities
MRI instruments
quantitate blood flow and construct images that look like MRA
types of low level disinfectant
quarternary ammonium N-alkyl T-spray II sani-cloth hydrogen peroxide atleast 3 %
effective calf muscle pump competent valves should prevent
reflux
Buerger's disease is also known as
thromboangitis obliterans
Plethysmography combines with doppler segmental pressures helps differentiate
true claudication from non-vascular sources
what dimensional view is standard for arteriography
two dimensional
penile non imaging technique calculate ABI placing cuffs on
upper arms and ankles ( refer to LE arterial )
occlusion may have _______ or ________ component
very low or absent diastolic
what kind of flow in opthalmic artery
retrograde
inferior vena cava terminates
right atrium
skin with dependency appears
ruborous red (dependent rubor)
high thigh knee cuff segmental pressure compresses which arteries
same as above the knee
optimize the doppler signal angle the CW doppler probe ______ degrees to the skin
45-60
deep femoral artery arises about ______ from the inguinal ligament of the lateral side
5 cm
digit plethysmography and pressures paper speed is slowed to
5 mm/sec
transducer type for duplex/color imaging of the abdomen in most adult patients
5, 3, 2.25 MHz linear array
with neointimal hyperplasia significant stenosis may occur within
6 to 24 months
Ideal Doppler angle for vascular exams
60 degrees
renal aortic ratio of > 3.5 suggests
60% diameter reduction
when doppler imaging of the penis what type is transducer is used
7 - 10 MHz
to image a hemodialysis access site with color/duplex imaging of the UE use a _________ transducer
7 or 5 MHz linear
what transducer is used to image LE venous?
7.5 Mhz or higher
what type of transducer should be used to evaluate brachial and radial arteries
7.5 or 5 MHz
interpreting transcutaneous oximetry TcP02- normal values with healing should occur with a p02 reading of
70 - 80 mmHg
Each beat of the heart pumps about
70 mL of blood into the aorta
how many branches does the ECA have
8
arterial doppler probe is usually
8- 10 Mhz
how much blood flow is carried to the liver through the portal vein
80%
vessel angulation behind the knee the probe angle may be closer to ______ degrees to the skin
90
high, semi and low fowlers position
90 30-45 head slightly elevated
abnormal EDR
< 0.2
normal RI
< 0.8
abnormal venous photo plethysmography VRT =
< 20 seconds
not reliable doppler angle
> 60 degrees
4:1 ratio =
> 75% diameter reduction
ABI within normal limits
>0.9 - 1.0
vasospasm velocities in the MCA
>120 cm/sec more severe >200 cm/sec
renal artery PSV of _______ will have post stenotic turbulence
>180-200 cm/sec
abnormal dorsal vein velocities in a doppler imaging study of the penis
>20 cm/sec
a horizontal segmental pressure difference of ________ suggests obstructive disease
>20-30 mmHg
PSV in the celiac artery that predicts >70% diameter reduction
>200 cm/sec
PSV in the SMA that predicts >70% diameter reduction
>275 cm/sec
an aneurysm in the aorto-iliac arteries has a dilation
>3 cm or an increase in diameter of 50% or greater than original artery
Segmental pressure drop of what between 2 consecutive levels would suggest significant obstruction?
>30 mmHg
with the 4 cuff technique the normal high thigh pressure is
>30 mmHg than the highest brachial pressure
if a ________stenosis diameter reduction is present in the UE arteries observe for characteristics of the stenosis profile
>50%
duplex/color imaging LE arteries can determine the presence/absence of
>50% diameter reduction or occlusions aneurysms
NASCET criteria
>70% stenosis defined as PSV >230 cm/s ICA/CCA ratio >4.0
4 pressure cuff has 2 thigh cuffs that can artifactually elevate
Blood pressures
Post-phlebitic syndrome
Chronic flow changes result in persistent edema, stasis changes, and pain May also lead to ulceration
Veins with valves
GSV SSV perforators popliteal femoral EIV CFV jugular vein basilic cephalic
what vein of the lower extremity is preopperatively mapped proximal to distal
GSV sometimes SSV
ausculatation
Listening with a stethoscope
Movement of any fluid medium between two points requires two things:
a pathway along which fluid can flow difference in energy levels (pressure difference)
dizziness
a sensation of spinning around and losing one's balance
fasciotomy
a surgical incision through the fascia to relieve tension or pressure
scaffold
a temporary platform used in work on a building
how is reactive hyperemia performed?
bilateral cuffs (19 x 40 cm) inflated to the suprasystolic pressure levels (above 20-30 mmHg above the higher brachial BP) maintaining for 3-5 minutes
qualitative abnormal signals
biphasic or monophasic
purpose of the cuff for LE doppler pressure exams
bladder inflation of the cuff transmits pressure quickly into the tissue to compress the artery
both arteries and veins carry same amount of
blood
with the doppler effect ______ is the moving target and ________ is a stationary source
blood trandsucer
veins are considered reservoirs for
blood collection
outflow represents
blood flow going out into the extremities
during transcutaneous oximetry TcP02 exam the elctrode is heated to 45 degrees celsius which causes
blood flow to increase lipid layer in fat tissue melts more 02 (oxygen) escapes through the skin and is measured by the sensor in the electrode
arterial injuries can result from what kind of trauma
blunt trauma, (bone fractures with injury to vessels) penetrating trauma (stab wounds)
with compartment syndrome the compartment is bound by
bone, fascia, and interosseous membrane which does not allow for expansion
peripheral UE veins may not completely compress secondary to
bony structures
peripheral veins in the UE are difficult to evaluate subclavian, innominate veins secondary to
bony structures
post excercice doppler pressures obtained where?
both ankles (abnormal ankle first) higher brachial
the brachial segmental pressure of the upper arm compresses which artery
brachial
placement of cuffs for the four cuff method for LE doppler pressure exam
brachial (upper arm) high thigh above the knee (AK) low thigh below the knee (BK) calf ankle
placement of cuffs for the three cuff method for LE doppler pressure exam
brachial (upper arm) one thigh cuff below the knee (calf) ankle
a >15-20 mmHg drop from upper arm to forearm suggest
brachial artery obstruction distal to the upper cuff obstruction in both radial and ulnar arteries obstruction in radial or ulnar artery which has a decreased pressure
segemental doppler pressures are obtained in the following order
brachial, ankle, calf, above the knee, high thigh,
where are the cuffs placed for a volume plethysmography exam?
brachial, thigh, calf, ankle bilaterally
branches of aortic arch
brachiocephalic trunk/ innominate, left common carotid artery, left subclavian artery
deep palmar arch includes which arteries
branch of the ulnar artery distal portion of the radial artery
ICA travels into the base of the skull with no
branching
dialysis access examples include
brescia-cimino fistula, straight graft, looped graft, synthetic graft
_________ created to portal vein
bridge
brawny
brownish discoloration
you can locate a patent dialysis as well as a stenotic one in the UE artery by auscultate access for _________ or palpation for _________
bruit thrill (vibration)
In the presence of significant stenosis or occlusion, a ___________ provides an alternate pathway for the blood to travel
bypass graft
diabetes has been associated with medial _______ in the _______ arteries
calcifications LE
cosine theta has to be
calculated cosine of 90 = 0
ejection fraction (EF) measures
calf muscle pump function
venous system starts at _______ level with progressive increase in size
capillaries (venules smallest, vena cava largest)
What governs the amount of blood that enters the arterial system?
cardiac output
what can lead to accelerated flow that is overestimated as stenosis
cardiac output tortuous vessel compensatory flow inappropriate doppler angle
bruit ausculation is more routinely done with ______ examination
carotid
MR angiography is used when a _________ study is equivocal (uncertain) or technically limited
carotid duplex
common sites for bruit evaluation
carotid, subclavian
how to perform an agioplasty exam
catheter tip is brought to the area of stenosis balloon slowly inflated, pushing plaque against walls of vessel and dilating the lumen balloon deflated, catheter removed
what to image when imaging the aorto-iliac arteries
celiac SMA renal arteries aorta- prox, mid, distal CIA bilat EIA bilat- prox, mid, distal IIA bilat
record velocities in first two branches off aorta
celiac and SMA
obtain the PSV and EDV on the following abdominal vessels
celiac artery SMA (prox, mid, distal) IMA aorta
median arcuate ligament also called
celiac band syndrome
with valvular incompetence the calf muscle pump no longer forces blood
cephalad towards heart or from superficial to deep system
CT is the most frequent application in cerebrovascular disease to evaluate the nature of
cerebral infarctions, intracranial aneurysms, hemorrhage and AVMs
Hypercoagulability caused by
certain protein deficiencies, pregnancy, cancer, homones - estrogen intake
Zero crossing frequency meter
circuitry counts each time the input signal crosses through zero (baseline) within a time span high frequency waves have many oscillations, low frequency have few direction of blood flow varies during the cardiac cycle machine estimates frequencies present in reflected signal and displays them
PVOD in the leg
circulatory condition in which narrowed blood vessels reduce blood flow to the limbs
ankle pressure =
circulatory pressure + 100 mmHg
types of chronic occlusive disease
claudication, ischemic rest pain, tissue loss
patient related issue one may experience hindering them from receiving an MRA
claustraphobia or expensive
it is important to obtain pertinent ________, _______, ________ and _______ prior to performing the study
clinical history, lab values, findings of physical examination, appropriate indication for testing
dicrotic notch
closure of the aortic valve and the influence of peripheral resistance
vein length is obtained in _______ and observed for _________ in preopperative vein mapping
cm continuity
vein wall ________ is evaluated for preopperative vein mapping
coaptation (compressibility)
digit plethysmogrphy and pressures fingers with cold stress is performed in cases of symptoms occuring due to
cold sensitivity (also be performed on toes)
a quick breath through pursed lips should
collapse UE veins
IMA can act as a _______ connection
collateral
deep femoral artery is also a common place for ____ connection
collateral
Arterial obstruction may alter flow in
collateral channels nearby or flow further away from site of obstruction
exercise can help determine the presence/absence of
collaterals
a normal waveform can accompany abnormal segmental pressures because of
collaterals can underestimate significance of obstruction based on plethysmography
color flow imaging indicating venous reflux
color changes noted during proximal compression maneuver or upon deflation of cuff
intraoperative imaging of the carotid identifies area of flow disturbance with
color flow doppler
Celiac trunk branches into
common hepatic artery left gastric artery splenic artery
most distal branches of the aorta
common iliac arteries
how to confirm abnormal findings in a bypass graft
compare previous studies and observe for changes
in an occluded artery the vessel lumen will be
completely filled with echoes
echoic or heterogeneous of all levels of echoes within vessel lumen
complex plaque intraplaque hemorrhage (sonolucent area inside plaque)
coaptation another word for
compressability
normal finding of veins is ____________ of veins without evidence of thrombus
compressibility
alternative of the allen test
compressing the ulnar artey to evaluate the radial artery (ulnar artery is harder to compress)
venous insufficiency in deep veins treated with
compression socks
cyanosis skin results in
concentration of deoxygenated hemoglobin; skin is bluish
Amaurosis fugax
condition in which a person cannot see out of one or both eyes due to a lack of blood flow to the eye
Atherosclerosis
condition in which fatty deposits, cholesterol and other substances called plaque build up on the inner walls of the arteries
inferior vena cava formed by
confluence of common iliac veins
axillary vein is formed by
confluence of the brachial and basilic vein
superior vena cava is formed by
confluence of the innominate veins
paired anterior tibial veins formed by
confluence of venules
paired peroneal veins formed by
confluence of venules
paired ulnar veins formed by
confluence of venules
coarctation of the aorta
congenital cardiac condition characterized by a narrowing of the thoracic aorta sometimes the abdominal aorta
arterioles assist with regulating blood flow through
contraction and relaxation
veno-motor tone
contraction of smooth muscles cells in veins that can occur in response to stimulation of sympathetic nervous system (temp, exercise, stress or trauma)
after catheter is placed for arteriography what happens next
contrast agent is injected into catheter and flows with moving blood, gives picture of lumen
medical treatment of contrast venography
control risk factors related to virchows triad
during transcutaneous oximetry TcP02 the electrode converts the chemical reaction to a ___________ reading which is converted to a ____________
current p02(oxygen) reading in mmHg
observe the kidney for morphological abnormalities such as
cyst or cortex thinning
scan throughout the popliteal fossa observing for any
cystic structures or masses
two preopperative vein mapping indications
determine suitability for extremity or coronary bypass determine suitability of veins for dialysis access/graft
purpose for penile imaging of the vessels
determine whether impotence is related to peripheral vascular insufficiency
at rest, total blood flow may be fairly normal even in the presence of stenosis/ complete occlusion of main artery. Why?
development of a collateral network and a compensatory decrease in peripheral resistance
example of calcified vessels in the LE & UE that can elevate doppler pressures
diabetics or end stage renal disease
main use of doppler/color imaging in the UE artery is evaluation of
dialysis access grafts
arterial flow proximal to AVF has greatly increased __________ flow and _________ resistance
diastolic low
what is clearly seen in an ECA waveform
dicrotic notch
Causes of hyperlipidemia
diet high in animal fat, metabolic problems associated with hereditary
IMA is ______ to locate and of easily imaged it suggests _______
difficult SMA occlusion
chronic and acute mesenteric ischemia is _______ to diagnose and requires a ________
difficult arteriogram
foot drop
difficulty lifting the front part of the foot
vertigo
difficulty maintaining equilibrium
fusiform anerurysm
diffuse, circumferential dilation
placement of cuff and PPG for digit plethysmography and pressures of toe exam
digit cuff placed at base of toe photocell securely attached to plantar side of toe using double stick tape or velcro strap
basilic vein is formed by
digital veins
cephalic vein formed by
digital veins
calcific shadowing from _________ and ________ makes it difficult to image LE arteries
diiabetes atherosclerosis
If BP falls, resistance vessels _____
dilate
abdominal and pelvis veins will ________ with deep inspiration
dilate
peripheral resistance decreases the arteries
dilate
percutaneous transluminal angioplasty (PTLA) is used to
dilate focal plaque formation in vessel in an angioplasty exam
soleal sinuses ( lower extremity venous sinuses)
dilated channels in the soleal and gastrocnemius muscles
rubor skin results in
dilated vessels or vessels dilated secondary to reactive hyperemia; skin is reddened
what suggests arterial insufficiency
diminished/absent pulse
How does a photocell work?
diode transmits infrared light into subcutaneous tissue which is reflected back to photo sensor light is not absorbed
How does PPG work?
diode transmits infrared light into subcutaneous tissue with backscattered light reflected back to the adjacent photo-sensor
blood flow must change _________ as the flowstream narrows entering the stenosis and enlarged as it exits
direction
when examining the vertebral arteries make sure to evaluate the __________ of flow
direction
TCD flow characteristics can show
direction velocity turbulence pulsatility systolic upstroke
patient may experience minor _____ with angioplasty
discomfort
results from sudden tear in the intima
dissection
non-atherosclerotic conditions
dissection, fibromuscular dysplasia, carotid body tumor, neointimal hyperplasia
veins are arteries located farther away from the heart are considered
distal
when we augment its _______ to the probe
distal
Steal syndrome
distal arterial blood flow is reversed into the lower resistant venous circulation causing pain in hand/finger on exertion, pallor, coolness of skin distal to the shunt
diabetes has a higher incidence of disease in the
distal pop and tibial arteries
superficial palmar arch includes which arteries
distal portion of the ulnar artery branch of the radial artery
If flow is Not spontaneous at the CFV, FV, or Pop V, an obstruction __________ that site is suggested
distal to
post stenotic turbulence is evident
distal to a > 50% diameter reduction
well collateralized occlusions appear similar to flow
distal to a stenosis
Distal to a stenosis, flow becomes at first appears _______ and then becomes _________
disturbed flow patterns (turbulent/ bi-directional) dampened and monophasic
non localizing symptoms of PCA lesion
dizziness, syncope, severe headache
reason to evaluate messenteric arteries with duplex/color imaging
document significant stenosis, evaluation of mesenteric bowel ischemia
purpose of venous photo plethysmography
document venous insufficiency, quanititative venous reflux in patients with chronic swelling, venous ulcers, varicose veins
penile pressures are obtained with _______ or ________
doppler ppg (end point detector)
Valasalva maneuver creates proximal compression while performing
doppler assessment of the lower extremities
spectral waveforms for helical flow vary
doppler shift above/below baseline doppler angle constantly changing spectral broadening not laminar flow
mirror imaging appears
doppler shifts above and below the baseline display duplicate spectrum or color flow doppler
digit plethysmography and pressure fingers without cold stress evaluates what
doppler signals (triphasic, monophasic, biphasic) palmer arch for patency pressure
doppler segmental pressure (LE) & (UE) are combined with
doppler velocity or volume pulse waveforms
post op evaluation of renal transplant
doppler, b-mode for hematoma and parenchymal echogenicity
ATA becomes the
dorsalis pedis artery
tracing is recorded for a venous photo plethysmography exam after
dorsiflexion or manual compression to record venous refill time/ venous reactive time (VRT)
dorsalis pedis artery courses across the
dorsum of the foot towards base of the great toe
diplopia
double vision
limitations of duplex/color imaging LE arteries presence of
dressings, skin staples, sutures, open wounds, incisional tenderness, hematomas
limitated access pertaining to color/duplex imaging of UE arteries due to
dressings, skin, staples, sutures, open wounds, IV site
pulsatile flow changes both the ______ and ______
driving pressure conditions response of the system
arterial ulcers will have trophic (abnormalities in the are of pain) changes of the skin
dryness, scaly, atrophy, shiny skin, loss of hair, thickened toenails
numbers of venograms has markedly decreased due to the accuracy of
duplex scanning
how to perform ablations
duplex scanning to confirm patency, size and depth of vein, confirm placement of the wire, guide injection of tumescent anesthesia, verify laser is firing correctly, assist with accurate pullback
documenting the ______ of ulcers is important
duration
how to incorporate results of post exercise pressures
duration of exercise length of time to recover pressure changes from pre to post exercise
Post-excercise what should you document
duration of walking MPH onset location progression of symptoms
appearance of an occluded artery will have varying degrees of
echogenicity
patient with SVC syndrome will show
edema and engorgement of vessels cough or difficulty breathing
visualization of the veins with color imaging may be difficult due to
edema, scarring, recent surgery, obesity
in DC the electrical voltage is
either positive or negative as current flows in only one direction
during transcutaneous oximetry TcP02 as oxygen escapes a chemical reaction occurs in ___________ located between ________ and _________
electrolyte solution skin and electrode surface
PSV and EDV vary as to type of dialysis access but, both are normally ________.
elevated
after initial calibration is recorded i supine position with air plethysmography legs are passively
elevated to empty venous system (zero venous volume)
Computerized Tomography (CT)
employs ionizing radiation to obtain cross sectional images of the aorta and other body structures
MR angiography
employs radio frequency energy and a strong magnetic field to produce images in multi planes
with popliteal entrapment syndrome flow to the great toe is monitored with
end point detector such as PPG
liver transplant treats patients with
end stage liver disease
surgical treatment for stenosis
endarterectomy, surgical removal of atherosclerotic material
indications of intravascular ultrasound
evaluate plaque formation on arterial wall post procedure to assess further treatment determine correct placement of stent identify aortic dissection applications for venous evaluation
during venous photoplethysmography exam patient is instructed to complete a series of
exaggerated dorsiflexions to empty calves veins also manual compression of calf can be performed
posterior to anterior flow
example PCA
what can lead to a false positive allen test (2)
excessive dorsiflexion of the wrist may compress radial and ulnar arteries if hand is opened and fingers forcibly extended the skin over the palm is stretched and can lead to pallor due to compression of small vessels
best single vasodilator of resistance vessels within skeletal muscle
exercise
inertial loss usually occurs at the ____ of a stenosis
exit
sources of false positive color flow studies
extrinsic compression peripheral arterial disease- decreased venous filling chronic obstructive pulmonary disease- elevated central venous pressure improper doppler angle or probe pressure
volume and photo plethysmography moderately abnormal waveform appears as
flattened systolic peak, upslope and downslope more delayed, reflected wave absent
Transient Ischemic Attack (TIA)
fleeting neurological dysfunction symptoms last less then 24 hours usually embolic from heart or carotid artery
greater the gradient the greater the
flow
Cross over collateralization
flow from contralteral vessel through communicating artery
late diastole
flow is forward again, as reflective wave hits the proximal resistance of the next oncoming wave, and reverses
at stenosis exit (post stenotic turbulence) flow appears as
flow reversals, flow seperations, vortices/ eddy currents appear near edge of flow pattern
_____ can differ in each lumen in an arterial dissection
flow velocities
thrombosis has the same echogenicity of
flowing blood on B-mode
pulsatile venous flow pattern evident with
fluid overload or congestive heart failure
pitting edema can be related to
fluid retention, congestive heart failure, elevated venous pressure
when reviewing the radial artery for preopperative arterial mapping what abnormalities should be observed for
focal elevated PSV, abnormal doppler quality, intimal thickening, aneurysm, calcification
ischemic rest pain due to chronic occlusive disease usually affects
fore foot, heels and toes
findings which could prevent use of vein as bypass graft or dialysis access
high bifurcation of brachial artery, duplicate venous system, presence of vein wall thickening or mural calcifications
intraoperative monitoring of the carotid uses what type of transducer
high frequency >12 MHz
intraoperative monitoring of a bypass graft uses a _________ transducer
high frequency imaging
alternating flow in the vertebral artery is angiographic evidence of
high grade subclavian stenosis
pumping action of the heart results in high volume of blood in arteries to maintain
high pressure gradiant between the arteries and the veins
ECA distributes blood to ____________ vascular beds
high resistance
with a subclavian steal the ispilateral vertebral artery is now feeding
high resistance vascular bed
Aorta and a fasting SMA and IMA have what kind of flow
high resistant
normal vasoconstriction or distal arterial obstruction can cause what kind of flow
high resistant
sublclavian artery typically appears
high resistant, multiphasic
stenosis doppler waveforms is characterized by ______ sound and waveform with _________ velocity
higher pitched higher
doppler spectra obtained at the stenosis what is documented
highest PSV
Renal to Aortic Ratio (RAR)
highest renal artery PSV / Aorta PSV
chronic changes of a vein in B-mode will appear
highly echogenic visible collateralization or recannalization vessel not dilated- may retract over time
contrast venography limitations
highly technical in technique and interpretation expensive uncomfortable
patients with leriche syndrome experience fatigue in
hips, thighs or calves with exercise
food challenge test _______ response begins after _______ minutes
hyperemic 10
food challenge test _______ response is approximately _______ minutes
hyperemic 30
incompetent veins lead to increased pressure/ venous
hypertension
reason for patient to recieve a exam of the renal arteries
hypertension (controlled or uncontrolled)
aortic dissection that extend into the iliac arteries are typically caused by
hypertension or severe chest trauma
less important risk factors of atherosclerosis
hypertension, diabetes, sedentary (sitting to long), arterial wall stress
purpose of intraoperative monitoring of carotid
identification of defects secondary to surgery or platelet aggregation evaluates hemodynamic significance of wall irregularity
capabilities of color flow in the peripheral veins
identify venous thrombosis detect calf lesions distinguish between extrinisc compression and intrinsic obstruction evaluate soft tissue mass detect venous incompetence recanalized channels or collaterals
reason the bp is lowered when moving distally
if the high thigh cuff is inflated to above systole and deflated then the next cuff above the knee is inflated it doesnt allow enough time for arterial blood to completely flow into the leg so the BP would be low
Bernoulli's Principle states
if velocity increases, pressure decreases in order to maintain the original total fluid energy amount
aortic dissections can extend into the
iliac arteries
spectral analysis is commonly used with
imaging modalities
post exercise ABI are obtained when?
immediatley after
causes for venous stasis
immobility, chronic obstructive pulmonary disease, obesity, pregnancy, previous DVT, extrinsic compression
dyslexia
impairment of the ability to read
___________ of the PPG sensor results in inaccurate information such as over a varicose vein
improper placement
potenional sources of error with doppler imaging
improper probe position inadvertent probe motion incorrect angle of incidence inadequate amount of gel excessive pressure on the probe tip insufficient period of rest before testing
emergency response systems available
in house emergency team community emergency number 911
when compression is a contraindication treatment of a pseudo aneurysm
inability to compress neck, patient on anticoagulation, multiple communicating channels
some limitations transcutaneous oximetry TcP02 can experience
inability to keep electrode fairly flat on the skin surface electrode placement must be on intact skin
secondary varicose veinsare dilated because of
incompetence of the superficial system resulting from a deep venous obstruction; deep system not intact
air plethysmography will not diagnose
incompetent perforators or isolated incompetent distal veins
fluid, RBC and firbrinogen may leak into surrounding tissue due to
incompetent valves
variscosities can also be a result of
incompetent valves
An ABI of > 1.3-1.5 is considered
incompressible/unreliable
in a normal doppler imaging study of the penis the cavernous arteries should _______ in size post injection
increase
source of error when solving for velocity is when the doppler theta angle _____________ its nonlinear influence as the angle becomes closer to 90 degrees
increase
inspiration in the venous system causes a ________ in intra-abdominal pressure and a ________ in blood flow from lower extremities
increase decrease
PPG can detect an ________ blood flow results in _________ attenuation which _________ its reflection which is displayed as a __________ of the waveform
increase increase decrease positive upstroke
induration
increase in fibrous elements in tissue commonly associated with inflammation; firmness or hardness of the skin surrounding the area of infection or inflammation such as abscess
in vasoconstriction pulsatile changes in medium/small sized arteries of the limbs are _______, pulsatility changes are _______ in the minute arteries
increased decreased
________ blood flow results in ________ attenuation which ________ this reflection which displays a ________ of the waveform
increased increased decreases positive upstroke
cause for stenosis located in the UE venous anastomosis and outflow vein
increased arterial pressure introduced to the vein intimal hyperplasia
increased heart rate delivers a
increased blood volume
B-mode signs of renal transplant rejection include: _____, _____
increased renal transplant size increased cortical echogenicity
changes in the waveform for arterial obstruction include
increased volume flow reversed flow direction increased velocity waveform pulsatility changes
Diminishing vessel size_____ frictional forces and energy loss in form of heat
increases
ineffective calf muscle pump volume and pressure ________
increases
lower extremities _______ with expiration and ________ with inspiration
increases decreases
spectral analysis
individual frequencies displayed by fast fourier transform (FFT) method
Fast Fourier Transform (FFT)
individual frequencies/ velocities displayed with time on horizontal axis and various frequency shifts/ velocities on vertical axis
Related to the tendency of a fluid to resist changes in its velocity
inertia
body at rest stays at rest
inertia
deviations from laminar flow due to changes in direction or velocity can cause
inertial losses
all bodily fluids are considered
infectious
phlebitis
inflammation of a vein
arteritis
inflammation of an arterial wall leads to thrombosis of the vessel
Temporal arteritis
inflammation of the arterial wall of the superficial temporal artery or its frontal and/or parietal branches
venous ulcers will have stasis (staying in one place) changes of the skin
inflammation, infection, brawny discoloration, presence of variscosities, lipodermatosclerosis
rapid cuff inflator required for quantitative evaluation for veous reflux
inflate 80mmHg thigh 100mmHg calf 120mmHg foot once pressure are obtained cuff is rapidly deflated
evaluation of the dialysis access grafts in the following order
inflow artery arterial anastomosis continue through body of graft observe for aneurysm, puncture sites, peri-graft fluid observe image for flow changes, turbulence, flow channel changes venous anastomosis outflow vein
vein bypass graft evaluates what parts of the artery, vein and graft
inflow artery proximal anastomosis entire length of vein bypass graft distal anastomosis outflow artery check for abnormalities (AV fistulas, valves)
snythetic bypass graft evaluates what part of the artery, vein and graft
inflow artery proximal anastomosis mid graft distal anatomosis outflow artery
most common location for a true aneurysm
infrarenal aorta
what approach can be used to visualize the distal subclavian vein
infreclavicular
common femoral vein becomes EIV when vein passes through
inguinal ligament
after measurement and velocities are obtained of the penis in a flaccid state specific medication is _________ into the _______ aspect, ________ shaft of the penis to induce erection
injected lateral proximal
color/duplex imaging is used to evaluate which arteries in the UE
innominate R/L CCA R/L axillary R/L brachial R/L radial R/L ulnar R/L palmar arch (if needed)
reduced amplitude with no changes in contour is likely to reflect ___________ disease unless it is ________
insignificant unilateral
all preventative electrical equipment and devices meet the
institutions safety code requirements such as frayed cord, cracked housing precludes safe use of transducer
common iliac arteries divide into
internal iliac artery and external iliac artery
epigastric artery is a terminal branch of
internal mammary artery
accleration time
interval between the onset of systole to the point of maximum peak
atherosclerosis formed within or beneath the
intima
Layers of arterial wall (inner to outer)
intima, media, adventitia
veins have the same three layers as arteries
intima, media, adventitia (medial layer very thin)
venous valves are extensions of
intimal layer
ICA does branch once it is
intracranial
transforaminal / occipital approach is used to evaluate what arteries
intracranial vertebral and basilar
endovascular stent graft designed to maintain
intraluminal structure and patency of the artery acts as a type of scaffold
according to bernoulli law velocity and pressure are _____related
inversely
The Bernoulli Principle states that velocity and pressure are
inversely proportional
atherosclerotic plaque on arteriography appears
irregular or smooth
fistula located peripherally more likely to cause
ischemia
primary raynauds results in
ischemia due to digital arterial spasm
more severe symptom of diminished blood flow due to chronic occlusive disease
ischemic rest pain
paired deep veins in the calf limit CW diagnosis of
isolated calf clot
what can lead to underestimated stenosis by missing accelerated flow
jet of acceleration flow missed long, smooth, plaque formation stenosis at area of dilation (carotid bulb) inappropriate doppler angle
popliteal vein is located
just behind the knee
small for circulating blood, expressed in terms of fluid density and velocity measurements
kinetic energy (velocity)
DF is a _________ value measured by the duplex
known
when evaluating for occlusion of the UE arteries look for
lack of doppler signals (image/waveform)
ataxia
lack of muscle coordination inability to control gait
even distribution of frequencies at systole
laminar flow
thrombus
large amounts of red blood cells trapped within a fibrin network; clumps of platelets may also be evident blood clot
temporal arteritis appears on b mode as
large in diameter with homogenuous thickening evident anechoic halo from edema of the intima may be seen
SSV has an important ________ perforating branch
lateral
PTA branches into
lateral and medial plantar arteries below medial malleolus to supply blood to the sole of the foot
paired radial veins empty
lateral hand and forearm
probe placement of non imaging penile pressure
lateral or ventral
where is the sensor applied in a venous photo plethysmography
lower extremitiy aprrox 5 to 10 centimeters above medial malleolus (must not be over a varicosity)
dissection creates a false
lumen that can extends proximal or distal
Trendelenburg position
lying on back with body tilted so that the head is lower than the feet 15-30 degrees
purpose of stent or graft
maintain intraluminal structure/ patency of artery / act as type of scaffold
plethysmography can not differentiate between
major arteries and collateral branches
evaluate compressability of the IJV from
mandible to where it joins the subclavian vein
gait
manner of walking
sphygomomanometer
manual blood pressure cuff
How to preform allen test
manual compression of the radial artery while patient clenches ispilateral fist (<1 min) inducing pallor which increases the resistant index then patient relaxes hand with continued manual compression of the radial artery
pittiing edema has a depression of skin surface with
manual pressure
Personal Protective Equipment (PPE)
mask, gloves, gown
Volume (air) Plethysmography
measurement of volume changes
evaluate the peroneal veins along the ________ calf
medial
basilic vein empties
medial aspect of the arm
peroneal artery courses along
medial side of the fibula
ulnar artery courses along
medial side of the forearm into the hand
external iliac artery travels along
medial side of the psoas muscle, passes under the inguinal ligament and becomes the CFA
treat for venous ulcers
medicated compression dressing using profore dressing- 4 layer unna boot- compression dressing made by wrapping layers of gauze around your leg or foot
leriche syndrome mainly affects which gender
men
the pain associated with mesenteric ischemia is called
mesenteric angina
pre-prandial high resistant waveform remains high resistant post-prandial suggests
mesenteric disease
patient presenting with dull, achy or crampy abdominal pain 15 - 30 minutes after meals are suspect
mesenteric ischemia
liver and spleen have fixed _______ not likely influenced by post-prandial state
metabolic requirements
presence of what can hinder MRA image
metallic clips, pacemakers, monitoring equipment
TIPS tract is stented with
metallic endoprosthesis (artificial device)
audible signals during a circle of willis surgery are related to _________ and may alter the surgical technique
micro-emboli
the frontal artery exits the orbit medially to supply
mid-forehead
ICA terminates at?
middle cerebral artery and anterior cerebral artery
venous ulcers will have ______ pain
mild
A normally high resistant (biphasic or triphasic) signal may become __________ as it approaches the significant stenosis and/or arterial obstruction.
monophasic
Thrombosis of the superficial system at or near the deep may require......
more aggressive treatment that an isolated superficial system thrombosis
ICA doppler singal characteristics
more high pitched and continuous than ECA wave has rapid upstroke and down stroke with a high diastolic component
no augmentation with proximal release consider
more proximal obstruction
oscillation
movement back and forth at a regular speed
patients cardiac status plays an important role in the
movement of blood throughout the vascular system
if it takes 6 - 12 minutes for the ABI to increase back to resting levels after they dropped to low or undetectable levels after exercise what kind of disease does that indicate
multi level disease
LE & UE doppler pressures can be difficult to interpret presence of ______ disease
multi-level
>50% drop in ankle pressure ABI with reactive hyperemia is associated with
multi-level disease
pulsed doppler beams evaluate ___________ throughout a specific area
multiple sample sites
scan rates are slower because of __________________ in each color line of site
multiple transmit/ received pulse cycles
differential diagnosis of acute DVT
muscle strain direct injury to leg muscle tear bakers cyst cellulitis lymphangitis heart failure extrinsic (outside) compression
popliteal artery gives off genicular branches that supply blood to the
muscles, knee joint and skin
symptoms not consistent with ICA lesions
myopia and homonymous hemianopia
flow is inversely related to what in pousilles law combined with resistance equation
n and L
best place to obtain aorta velocity
near SMA
venous ulcers are typically located
near medial malleolus (bony projection of ankle)
myopia
nearsightedness
thoracic outlet syndrome involves which arteries
neurogenic compression of brachial plexus (97%) small percentage due to subclavian vein or artery compression
pseudo claudication mimics vascular symptoms but is _______ or _______ in origin
neurogenic; orthopedic
surgical treatment fr occlusion
no surgical intervention
Drawbacks of Analog
noise, less sensitivity, high velocities are underestimated, low velocities are overestimated
functional (intermittent) obstructive disease has _______ doppler arterial signals ________ systolic pressures and _________ PPG tracings (plethysmography)
normal normal normal
secondary raynauds caused by
normal vasoconstrictive response of arterioles superimposed on a fixed artery obstruction
angioplasty procedure can _______ be peformed in all vessels with focal stenosis
not
ischemic rest pain due to chronic occlusive disease occurs when limb is _______ and BP ______
not dependent decreases
in a normal doppler imaging study of the penis the doppler veins should ________ in size
not increase
food challenge test
not routinely done, patient ingesting high caloric liquid (ensure) exam repeated 20-30 minutes after ingestion (sooner if symptomatic)
difficult to preform volume plethysmography on _______ patients
obese
if cuffs are applied to tight for volume plethysmography
obliterate or diminish the pulse waveforms
intimal flap
observation of the intimal layer of a vessel as a result of a dissection
The location of collateral channels can help to provide a tentative indication of the ____
obstruction
a difference of >20 mmHg between radial and ulnar pressures suggest
obstruction in vessel with lower pressure
thrombembolic
obstruction of a blood vessel be a piece of thrombus
Leriche syndrome
obstruction of the aorta
Superior vena cava syndrome
obstruction, neoplasm, dialysis catheter or central line that interrupts blood flow medical emergency
secondary raynauds is also knows as
obstructive raynauds syndrome
before perforing the doppler imaging exam of the penis whats the first thing you need to do
obtain informed consent
Budd-Chiari syndrome
occlusion of hepatic veins
arteritis patients present with
occlusion of the distal arteries, rest pain and ischemic ulceration
absent doppler signals suggest
occlusion or pre-occlusive disease (string sign)
dissecting aneurysm
occurs when a small tear of the INNER wall allows blood to form cavity between two wall layers
plug flow
occurs when all of the layers and blood cells travel at the same velocity
each perforator contains how many valves
one
how many planes are used with CT imaging
one
normally the calf expends >60% of the venous volume with
one toe up
electrical coupling allows
one type of current to pass and blocks the other type
plethysmography can not be specific to
one vessel it detects all arterial flow beneath the cuff
clinical presentation of arterial injuries
open wound, hemorrhage, hematoma, absence of distal pulses
supraorbital artery arises from
opthalmic artery
technique to compress pseudo aneurysm
patient signs consent form alternating compressions 10 - 15 minutes with short rest with MD present monitor distal perfusion
how to perform thrombin injection of a PSA
patient signs informed consent PSA, neck, adjacent vessels identified MD mixes thrombin solution insert needle into PSA slowly injects until thrombosis occurs (few seconds) monitor distal perfusion
patient positioning of a TCD exam
patient supine and avoids speaking during exam
patient positioning for LE artery duplex/color imaging
patient supine with head on pillow extremity positioned close to examiner patient hip minimally rotated externally, with knee flexed prone or lateral decubitis may be needed for assessment of popliteal artery
tehnique used to evaluate exercise pressures
patient walk on a treadmill at a <12% incline speed: 1.5 mph for duration of 5 minutes or until symptoms increase to such severity that the patient must stop
limitations of arterial doppler waveform
patients with casts or bandages waveforms can be affected by ambient temperature (air temperature) uncompensated congestive heart failure may result in dampened waveforms unable to differentiate stenosis from occlusion technically dependent test
sumner and strandness describe
peak pulse seen in the digit pulse contours of patients with raynauds phenomena
pulsatility index (PI) calculated by dividing
peak to peak frequency difference (P1-P2) by the mean frequency
in transverse _________ can be calculated
percent stenosis
exercise will induce
peripheral vasodilation which decreases distal peripheral resistance, increases blood flow
embolism
piece of thrombus breaks loose and travels distally until it lodges in a small vessel
free flap surgery
pieces of tissue from one part of the body are surgically remodeled and then brought to a new part of the body
technique when places the LE doppler pressure cuff
place cuff straight on extremity not encircling a bony prominence fit snugly cuff bladder should be placed directly over artery
how to locate the CFV with CW exam
place probe at inguinal ligament, identify CFA and angle probe medially to find CFV and evaluate venous doppler signals
_______ and ______ distribute blood to the the digits of the foot
plantar and dorsal metatarsals
vessels are followed from clavicle to mandible in transverse to document
plaque formation
penile imaging uses what 3 types of imaging
plethysmographic duplex doppler
PPG not true
plethysmography
to preform the volume plethysmography exam _________ are placed around specific levels of the extremities or digits
pneumatic cuff (inflatable air cuff)
Diminished CCA velocities bilaterally may indicate...
poor cardiac output or stroke volume
causes of an aneurysm are unknown but can be related to
poor nutrtition, congenital defect, infection or atherosclerosis
thrombus formation may be _________ attached or have __________ texture
poorly spongy
popliteal artery entrapment syndrome
popliteal artery is compressed by medial head of gastrocnemius muscle (anomalous in origin, not in normal spot) or fibrous band
with the knee extended and active plantar flexion or passive dorsiflexion of the foot, PPG pulsations diminish or obliterate it is suggestive of
popliteal entrapment syndrome
muscular gastrocnemius veins drain into
popliteal veins
Transjugular intrahepatic portosystemic shunt (TIPS) shunt between
portal and hepatic vein
during inspiration there is minimal flow fluctuation in what abdominal vein
portal vein
pre and post operative of a liver transplants requires documentation of patency of
portal veins hepatic veins IVC hepatic artery tissue abnormalities
minimally phasic, continuous doppler signals in
portal, splenic and messenteric veins
air plethysmography documents volume changes secondary to
position changes/ exercise
usually pressures for a qualitative doppler study are obtained
post exercise
never accept the value of numbers alone to prove pre-stenotic and stenotic velocities ________ should be present too
post stenotic turbulence
basilar artery divides into
posterior cerebral arteries
inappropriate doppler angle usually negates the ability to insonate (expose)
posterior communicating arteries
posterior cerebral arteries are joined together by the
posterior communicating artery
when evaluating the verterbral arteries use _________ approach
posterior lateral
if greater then 50% diameter reduction is suspected in the LE obtain
pre stenotic PSV (approaching the stenosis) PSV (highest) in stenosis post stenotic turbulence
what can limit evaluation of duplex color imaging of the carotid
presence of dressings, sutures, skin staples size or contour of neck depth or course of vessel acoustic shadowing from calcification
to make a conclusion about a steal after the exam is performed if flow improves steal is __________ if flow does not improve steal is _________
present probably not present
pulsed doppler the spectral window is
present still able to be seen
reynolds number evaluates what relationships
pressure and flow
during plethysmography volume after volume is converted into pulsatile pressure changes a pressure transducer converts
pressure changes into analog waveforms for display on strip-chart recorder
once catheter is removed for arteriography exam what is done
pressure held on a puncture site; patient must stay supine for 6-8 hours, sandbag placed on top of dressing to avoid bleeding
process of blood traveling from the left ventricle to the aorta
pressure in the left ventricle rises, pressure exceeds that of the aorta which causes aortic valve to open and blood is ejected causing blood pressure to rise
extrinsic compression is caused by
pressure on vessels from surrounding tissue can cause abnormal flow
normal toe/brachial (TBI) indices (used in digit plethysmography and pressures)
pressure varies 60-80% of brachial pressure
heart pumping results in a ______ that travels rapidly throughout the system which demonstates a gradual transformation as it moves ______
pressure wave (energy wave) distally
two types of raynauds
primary raynauds and secondary raynauds
easy place to locate posterior tibial veins
probe between medial malleolus and achilles tendon
how descending venography works
radio-opaque contrast media injected into CFV serial x-rays taken as material passes through veins to detect and quantify reversed flow and location of incompetent valves
how ascending contrast venography works
radio-opaque contrast media injected into vein on dorsum of foot to visualize anatomy serial x-rays taken as media passes through vein identifying filling defects, anatomic variations, development of collateral channels
arteriogram
radiographic image of an artery (after an injection of contrast media)
CW doppler has no
range resolution
pulsed doppler has
range resolution and well defined spectrum
flouroscopy
rapid film changer technique used to expose films as contrast agent moves through vessel
biphasic flow
rapid upslope sharp peak fairly rapid downstroke flow reversal no resumption of forward flow can be considered normal in some patients
Kippel-Trenaunay Syndrome
rare congenital vascular disorder in which a limb is affected by port wine stains (red/purple birthmarks involving blood vessels), varicose veins, too much bone or tissue growth
venous filling (VF) index shows
rate of venous refilling
type of vasospastic disorder
raynauds phenomenon
troubleshooting for plethysmography - unable to obtain clear waveform?
reapply the PPG; patient tremors make exam impossible
how to perform CW
recorded off audible noise no sample volume no angle no velocitieswhich
epigastric artery supplies blood to
rectus abdominis muscle vertically oriented on each side of mid line
two doppler shifts
red blood cell is first an observer of a stationary ultrasound field act as a wave source when the waves scatter from its surface
erythma
redness of inflammatory process such as cellulitis
Abnormal plethysmographic signals obtained during a non imaging penile pressure study show ___.
reduction in amplitude
"peripheral"
referring to arteries away from the heart
Continous Wave Doppler
reflected frequency is higher/lower then the transmitted frequency depending on the direction of flow
cutaneous blood flow determines the amount of
reflection
transcutaneous oximetry TcP02
reflects tissue oxygen tension and relies on a balance between oxygen supply and consumption
ineffective calf muscle pump incompetent valves will cause
reflux
augmentation during a valsalva maneuver signifies
reflux/ retrograde flow
fluid accumulates in the lymphatic system when lymph nodes and or lymph vessels
removed or damaged
CT also helps identify the relationship between aorta to
renal artery origins
many patient who have hypertension have renovascular hypertension causes by
renal artery stenosis or occlusion
which arteries of the kidney are recorded PSV EDV bilaterally
renal artery- prox, mid, distal segmental arteries- upper, lower pole
flattened shape of vein offers more _______ then circular shape
resistance
viscosity and vessel length have an effect on
resistance
multiple obstructions in the same vessel results in
resistance to flow is additive resulting in a higher resistance then in each individual narrowing
Obstructions in different vessels that are parallel results in
resistance to flow is less than the resistance in each individual narrowing because only part of the blood is going through each narrowing
consider disease at the carotid siphon when _________ flow patterns are present in the ICA
resistant
absolute ankle pressure ABI has a .5 has a stronger weight for predicting symptoms at
rest
before performing lower extremity doppler pressure the patient should ______ 20 minutes prior especially if ________ disease is present
rest vascular
different arm positions for thoracic outlet syndrome
resting position hand in lap arm at 90 degree angle arm at 180 degree angle exaggerated military stance adson maneuver positioning -same as military head turn to the right and to the left causative position as described my patient
to prove claudication compare
resting values to obtained after excercise
interpretations of venous exam should include
results compared to prior study limitations of exam included in report preliminary interpretation should be provided to the referring physician
some _______ flow might be evident at the distal anastomosis of a RSVG which provides a source of collateral flow
retrograde
what kind of flow in the PCA
retrograde increased flow
spectral analysis indicated venous reflux when
reverse flow last more then 0.5-1 second using the proximal compression maneuver or utilizing the standing duplex
descending venography is used to detect and quantify
reversed flow from venous reflux
portal hypertension is increased portal venous pressure can result in a variety of flow atlerations
reversed flow in portal vein collateral development
in AC the electrical voltage
reverses polarity (positive or negative) 60 times a seconds as current flows in both directions
median arcuate ligament is a _________ celiac artery stenosis that occurs during ______
reversible expiration
what signifies adequate circulatory status
rhythmic throbbing of artery in time with heartbeat
Palpation
rhythmic throbbing of artery in time with the heart beat usually felt by the 2nd, 3rd, and 4th fingers
usual approach for TIPS
right IJV to IVC to hepatic vein
SVC carries blood to which chamber of the heart?
right atrium
superior vena cava terminates at
right atrium
IVC carries blood into
right atrium of the heart
special attention is given to which arteries in the neck for duplex/color imaging
right innominate artery left CCA
left hemisphere of the brain controls
right side of the body
left hemispheric CVA results in neurological deficits on the
right side of the body
rouleau comes from a french word meaning
roll
with rouleau formation RBC arranged like a
roll of coins
other not so common positions for LE doppler
rt/ lt lateral decubitis or prone
superficial femoral artery course
runs the length of the thigh and passes through an opening in the tendon of the adductor hiatus and enters the popliteal fossa
most frequent complication of an aneurysm
rupture aortic aneurysm, embolization of the peripheral aneurysm
a test procedure is not carried out if the examiner determines the patient cannot
safely tolerate or cooperate with safety protcol
the vertebral arteries are evaluated in __________ view
sagittal
patient with SVC syndrome UE remains the ________ during inspiration
same
if one large thigh cuff is used the knee segemtal pressures compresses which arteries
same as calf
for above the knee cuff segmental pressure compresses which arteries
same as calf may use the popliteal artery
CW doppler has a fixed
sample size
pulsed doppler has variable
sample sizes
how to perform sclerotherapy
sclerosing agent (sodium tetradecyl sulfate) injected into varix and compression dressing applied
patient positioning for venous photo-plethysmography exam
seated with legs dangling, non-weight bearing
the machine for volume plethysmography performs a ________ __________
self calibration bilaterally
pulsed wave doppler
sends out a pulse signal to a certain depth then stay quiet and listen for for the reflected frequency shift and calculates the velocity of flow at a chosen point
accuracy caluclation falls between
sensitivity and specificity and also PPV and NPV
Phlegmasia cerulea dolens
severely reduced venous outflow from iliofemoral thrombosis which reduces arterial inflow; limb threatening
volume and photo plethysmography mildy abnormal waveform appears as
sharp peak, absent reflected wave, downslope is bowed away from baseline
Contraindications of exercise evaluation pressures
shortness of breath, severe hypertension, significant cardiac problems, stroke, walking problems
spontaneity
signal immediatley heard at all sites except PTV
ECA doppler signal characteristics
signal more pulsatile; similar to peripheral vessels rapid upstroke and down stroke with low flow in diastole
with venous photoplethysmography significant difference in tracing should mean
significant difference in blood volume
with the 3 cuff technique the normal high thigh pressure is
similar to the highest brachial pressure
if it takes 2 - 6 minutes for ABI to increase back to resting levels after they dropped to low or undetectable levels after exercise what kind of disease does this indicate
single level disease
portal vein carries blood into
sinusoids of the liver (hepato-petal flow)
hydrostatic pressure is mainly affected by a patient in the _______ position
sitting
patient positioning for digit plethysmography and pressure of the finger
sitting with arms resting on pillow placed on patients lap
transducer selection for duplex/color imaging of the abdomen is related to the _________ of the patient
size
CT can help to identify _____ of aorta along with ______ and ______ of aneurysm
size extent and size
venous photoplethysmography is important to maintain the same ________ or _______ setting throughout study
size gain
first step to treating a pseudo aneurysm is to determine
size and location of pseudo aneurysm and size and location of neck
how to perform transcutaneous oximetry TcP02
skin cleansed with alcohol wipe; air dried airtight self adhesive fixation ring placed on skin few drops of electrolyte solution put inside ring electrode/sensor affixed to fixation ring
normal PSV in the UE arteries varies widely with
skin temperature
The strip chart recorder should be set at a speed of:
slow speed usually 5 mm/sec
monophasic flow
slow upslope rounded peak slow down-stroke no reversal
abnormal obstructive waveforms post finger cold stress test for digit plethysmography
slow upstroke to rounded peak downslope that bows away from the baseline
doppler waveform abnormal post exercise
slow upstroke with more rounded peak, slow downstroke, no reverse component
acceleration time helps prove that proximal arterial obstruction results in
slowing of time to the peak
____ changes in the radius might result in _____ changes in the volume flow
small large
SMA supplies blood to the
small intestine, cecum, colon
_________ changes required to expand or distend vein from normal dumbbell shape to a circular one
small pressure changes
vasa vasorum
small vessels that supply blood to the walls of the larger arteries
right vertebral artery is usually __________ then the left
smaller
Major risk factors for atherosclerosis
smoking, hyperlipidemia, family history
arteritis can be associated with
smoking, men <4o years of age and buergers disease
surface characteristics of a vessel
smooth, slightly irregular or grossly irregular surface
with MRI flowing blood is well distinguished from _________ without contrast agents
soft tissue
emboli may be composed of
solid, liquid or gaseous
frontal artery joins the ECA by
some of its branches
Phasicity
sound varies with respiration
REMEMBER ultrasound uses plethysmography uses ABI uses
sound waves infrared light blood pressure
the doppler effect occurs with relative motion between _______ and ______ of sound
source receiver
intra cranial venous sinus
spaces between dura mater and periosteum that drain blood into the IJV
ENTRANCE into stenosis produces an increase in Doppler shift frequencies (DSF), resulting in:
spectral broadening and elevated velocities
the spectral pattern will appear ______ at the exit of a stenosis
spectral broadening due to the multiple changes in flow direction
two ways to obtain doppler segmental pressures in the LE
sphygmomanometer or automatic cuff inflator
flow seperations can result in regions with
stagnant or little movement
after legs reach a zero venous volume in air plethysmography exam patient must immediatley
stand bearing weight on contralateral leg causing increase in venous volume which is documented on a strip chart recorder
coma
state of profound unconsciousness
TCD is effective in evaluating for intracranial
stenoses, occlusions and assess collateral circulation
currently no criteria for classifying ______ in the UE arteries like there is in the LE
stenosis
Doppler segmental LE & UE pressures cannot discriminate between
stenosis or occlusion localize area of obstruction CFA or external iliac disease
intimal thickening due to temporal arteritis may result in
stenosis where PSV are doubled
reason to evaluate aorto-iliac vessels with color/duplex imaging
stenosis, bypass graft, aneurysmal disease
complications due to arterial dissections
stenosis, occlusion, thrombosis, death from rupture of aortic dissection
uncommon for arteries in the upper extremities to become
stenotic
_________ is not considered a disinfectant agent
sterile saline
how to preform intraoperative imaging of carotid
sterile sleeve/ plastic bag containing gel wound filled with sterile saline
Proximal high grade stenosis or occlusion of the renal artery may result in what type of waveform?
still low resistant
celiac artery supplies blood to
stomach, liver, spleen, pancreas, duodenum
lifestyle modifications to enhance blood flow
stop smoking consistent exercise to enhance collateral development weight control and a low cholestrol diet may enhance normal endothelial cell metabolism protection to prevent injury or infection
types of way to break down clots with lytic therapy
streptokinase urokinase
Distal effects of obstructive disease may only be detectable following
stress
Paget-Schroetter syndrome
stress/effort thormbosis in the UE venous component Thoracic outlet syndrome (TOS)
reactive hyperemia is an alternative method for
stressing the peripheral circulation
Chronic Venous Insufficiency (CVI)
stretching of walls results in damage to valves increased venous pressure causes flow changes
Mirror image artifact caused by
strong reflector or too much gain
patient position for air plethysmography exam
study starts with patient supine then patient assumes a variety of positions
troubleshooting- venous photoplethysmography - artifact from patient movement?
study technically impossible
verterbral arteries are branches of the _____ artery
subclavian
doppler velocities typically recorded bilaterally in the upper extremities
subclavian axillary brachial (at elbow antecubital fossa) radial (thumb site at wrist) ulnar (5th finger side at wrist)
pulsatile doppler signals is evident in what UE veins
subclavian and innominate
vertebral arteries is the first branch off of
subclavian artery
intraoperative imaging of the carotid used gray scale imaging to detect
subtle wall defects
radial artery branches into
superficial palmer arch and terminates in the deep palmer arch
Kippel-Trenaunay Syndrome can include multiple varicosities of the
superficial system
venous photoplethysmography shows VRT < 20 seconds without tourniquet but normalizes to > 20 seconds with tourniquet is an exmaple of
superficial system incompetence
supraorbital joins the ECA via some of its branches such as
superficial temporal artery
Perforators carry blood from _______ to ______
superficial; deep veins
portal vein is formed by
superior mesenteric vein and splenic vein
ECA branches in ascending order
superior thyroid ascending pharyngeal lingual facial occipital posterior auricular maxillary superficial temporal
patient positioning with lower extremity doppler pressure exam
supine legs same level as heart
patient positioning for duplex/color imaging study of the abdomen
supine minimal head elevation left lateral decubitis for access to right flank right lateral decubitis for access to left flank creative patient positioning and scanning approaches to optimize study
patient positioning to image UE peripheral veins
supine or low fowlers position arm in pledge position
after toe raises are performed for air plethysmography patient quickly resumes to
supine position and legs are elevated to drain veins
patient positioning for a UE arteries duplex/color imaging exam
supine with a small pillow under head extremity close to examiner arm is at a 45 degree angle from the body externally rotated (pledge position)
patient positioning of penile imaging
supine with appropriate imaging draping done to maintain privacy
patient positioning for UE doppler pressure
supine with arms relaxed at patients side
patient positioning for CW venous exam
supine with body shifted to side being examined leg externally rotated with hip and knee flexed position should facilitate venous filling (extremities lower then heart)
patient positing for abdominal and pelvic veins
supine with head slightly elevated left lateral decubitis with head elevated slightly reverse trendelenburg whatever works
patient positioning for a plethysmography
supine with limbs in a resting position can be sitting for evaluation of upper limb digits
patient positioning for digit plethysmography and pressure of the toe
supine with some elevation of the head
most common patient position for LE doppler
supine with the extremities at the same level as the heart patient hip is externally rotated, knee slightly bent
patient positioning for transcutaneous oximetry TcP02 exam
supine, head slightly elevated, room is warm
patient positioning for volume plethysmography
supine, heels slightly elevated on cushion
best way to evaluate the proximal subclavian vein
supraclavicle approach
periorbital circulation consists of what arteries
supraorbital artery frontal artery
purpose for preoperative arterial mapping of the epigastric artery
surgeon wants to use best arterially supplied muscle section for TRAM flap for autogenous (arising from within) breast reconstruction
brescia-simino fistula
surgical connection typically between an artery and vein
bypass graft
surgical creation of a diversion for the bloodstream by suturing a graft to blood vessel so that blood bypasses an obstructed or weakened portion of the vessel
reason to evaluate liver with duplex/color imaging
suspected portal hypertension, pre/post liver transplants
most common findings during chronic venous disease
swelling heaviness discoloration ulcers varicosities
Resolving Ischemic Neurological Deficit (RIND)
symptoms last more then 24 hours complete recovery
permanent symptoms of a cerebrovascular accident involve
symptoms that last more then 24 hours complete recovery does not occur
TCD exam with AVF has increased _______ and _______ flow velocities
systolic and diastolic
when obtaining doppler segmetal pressures you must start at the ankle and move proximally to eleminate the possibility of underestimating the
systolic pressure measurement
oscillations seen in waveform with
tapping STA (superficial temporal artery)di
increased BP _____ the heart
taxes
embolization
technique used to block blood flow to a site by passing a catheter to the area and injecting a synthetic material or medication specially designed to occlude the blood vessel providing blood to a tumor
Specificity
the ability of the test to correctly identify those without the disease (normalcy)
range resolution
the ability to determine how far away a reflector is so it can be displayed on the screen; without range resolution there is depth ambiguity
fatty streak
the first grossly visible (visible to the naked eye) lesion in the development of atherosclerosis. It appears as an irregular yellow-white discoloration on the luminal surface of an artery.
to record patients temperature use two ways
touch patients skin to determine warm/ cold utilize skin thermometer to document precisely
if any abnormal findings found upon air plethysmography exam the study is repeated after
touniquet applied to eliminate influence of superficial system
during venous photo plethysmography if the VRT is <20 seconds the study must be repeated after
tourniquet applied to eliminate influence of the superficial system
cephalad
toward the head
calf muscle pump muscle contraction squeezes vein propelling blood
toward the heart
Photo-plethysmography (PPG) consist of
transducer, amplifier, strip-chart recorder
transient cerebrovascular accidents
transient ischemic attack resolving ischemic neurological deficit vertebral basilar insufficiency
syncope
transient loss of consciousness due to inadequate blood flow to brain
__________ should be provided if a language barrier exists between the patient and the healthcare provider
translator
The shape of a vein is determined by:
transmural pressure
__________ approach of TCD imaging can be limited by recent eye surgery
transorbital
______ view do you asses for compressability
transverse
endovenous treatment of varicose veins (ablations)
treat the veins from the inside using heat energy that causes the vein to shrink then slowly disappear
change from _____ flow to _____ flow of a bypass graft is considered abnormal
triphaic biphasic
doppler signal quality in the UE arteries is
triphasic
qualitative normal signals
triphasic
normal LE arteril flow is
triphasic a change to biphasic is significant
how to characterize the doppler signals of the LE
triphasic, biphasic, monophasic exam for spectral broadening
thinner then media, contains fibrous connective tissue, some muscle fibers
tunica externa (adventitia)
thin layer, consisting of smooth layer endothelium, base membrane, connective tissue
tunica intima
thick layer, composed of smooth muscle and connective tissue, largely of the elastic type
tunica media
trauma can also cause an intimal tear with what still remaining in tact?
tunica media and adventitia
Continuous Wave doppler (CW)
two piezo-electric crystals- one constantly sending and one constantly receiving reflected waves
coronary artery bypass
type of surgery that improves blood flow to the heart
when documenting a bypass graft in the LE you need to know
type, location and age
lymphadema is frequently seen after
types of cancer surgery
Predominate source of blood flow to the hand
ulnar artery
reappearance of normal color after the allen test is performed indicates
ulnar artery is providing flow to the palmer arch (normal)
color does not reappear after the allen test is performed indicates
ulnar artery occlusion or palmer arch obstruction (abnormal)
IVC and pelvic veins evaluation begins in TRV view at the level of the _______and other abdominal vessels evaluation begins at the _________
umbilicus xiphoid process
Air Plethysmography (APG) is limited due to patient
unable to maintain positions or perform exercises casts, traction, heavy non-removable bandages
what can result in decrease pressures in the ankle or brachial
uncompensated congestive heart failure
do not use what to clean ultrasound probe
undiluted bleach, abrasive cleaners, solvents
bicuspid structures provide __________ flow
unidirectional
key to successful treatment of pseudo aneurysm is to determine whether the neck/ communicating channel between the artery and psuedo aneurysm can be
uniformly and completely compressed
Symptoms frequently seen with ICA lesion
unilateral paresis, unilateral paresthesia, aphasia, amaurosis fugax
a vessel with a < 60 degree angle is still
usable
how to assess a possible steal
use PPG to evaluate flow in atleast 2 digits one at a time apply manual pressure to dialysis access retake PPG or pressure
sclerotherapy
used in the treatment of spider veins (small varicosities)
how is arterioraphy recorded once contrast is injected into catheter
using flouroscopy
ulnar artery aneurysm can occur in response to
using the palm as a hammer
acute thombosis usually occurs where
valve cusps or soleal sinus secondary to stagnation
primary varicose veins are dilated veins secondary to
valvular incompetence of superficial system; deep system intact
there is a _______ number of valves in the UE deep veins
variable
adventitial layer contains the
vasa vasorum
Abnormal penile/brachial index indicates
vasculogenic impotence
TCD can evaluate onset, severity and time course of
vasoconstriction from subarachnoid hemorrhage
As the inflow pressure falls as a result of stenosis, what is the natural response of the periphery vessels? Vasodilate or vasoconstrict?
vasodilate to maintain flow
post procedure of ablation duplex scanning used to confirm
vein ablation and absence of thrombosis
treatment for chronic venous insufficiency
vein ligation of incompetent perforators less frequent- valvular reconstruction or valve transplantation
the law of conversation of mass explains the relationship between
velocity and area
velocity acceleraton results in a stenosis because
velocity and area are inversely proportional
Benoulli's Principle evaluates the relationship between
velocity and pressure
the paired deep veins of the arm follow the corresponding artery called
venae comitantes (corresponding veins)
the paired deep veins of the calf follow the corresponding arteries are called
venae comitantes (corresponding veins)
veins have some level of reactivity which may be referred to as
veno-motor tone
most common site for stenosis in the UE
venous anastomosis and outflow vein
purpose of air plethysmography is to evaluate for
venous function and document venous insufficiency / quantitative venous reflux
if doppler velocities of the dorsal veins increase what could that suggest
venous leak
venous ulcers will have _______ bleeding
venous ooze
If flow increases during proximal compression, that signifies:
venous reflux
flow reversal in response to valsalva maneuver or during proximal manual compressions indicates
venous reflux
posterior arch vein plays a major role in the development of
venous stasis ulcers
Valves of the lower extremities are more susceptible to disease secondary to the effects of _______
venous thrombosis, increased ambulatory venous pressure from gravity, increased intrabdominal pressure, venous obstruction
venous filling is calculated using
venous volume (VV) and venous filling time (VFT)
posterior circulation of cerebrovascular arteries
vertebral and basilar arteries
what arteries unite after entering the skull to form the basilar artery
vertebral arteries
some branches off the subclavian artery
vertebral, thyrocervical, costocervical
symptoms frequently seen with vertebrobasilar lesion
vertigo, ataxia, vision blurring, diplopia, bilateral paresthesia, drop attack
as femoral vein passes through adductor canal it can become
very difficult to compress
Rouleau formation
very sluggish flow in a vein seen as heterogenous material moving in vein with respirations and augmentation
pulsatile mass in neck usually
very tortuous CCA
abdominal and pelvic veins may be difficult to evaluate due to
vessel depth and presence of gas
most dramatic effect on resistance of flow is
vessel diameter
resistance is inversely proportional to
vessel radius
why are the peripheral veins in the LE hard evaluate
vessel size, depth, course
severe anemia decreases blood
viscosity (blood thinning)
elevated hematocrit increases blood
viscosity (thickness of blood)
steady flow in a rigid tube energy losses are mainly _______ and can be described as _______
viscous poiseuilles equation
increased friction between molecules and layers which ultimately causes energy loss
viscous energy
limitations to preopperative arterial mapping of the radial artery
wall calcification
example of AC
wall plugs deliver 120 volts of AC
digit plethysmography and pressure exam the patient should be kept as _________ as possible
warm
if plethysmography waveforms of the toe are poor first try
warming the toes
unilateral paresis
weakness or slight paralysis on one side of body
how does a pulmonary embolism occur
when a thrombus breaks free from elsewhere in the venous system and migrates into a pulmonary artery
the doppler effect
when a wave is reflected from a moving target, the frequency of the wave is received different (doppler shift) from the transmitted wave
when do you use proximal release augmentation?
when distal augmentation is not enough to prove reflux
how to perform digit plethysmography and pressure exam
while pulsations are recorded cuff is inflated to 20-30 mmHg above highest brachial pressure no pulsations seen cuff slowly deflated watching for return of first pulse to define the pressure level
vortex & eddy currents
whirling with little to no forward motion, circular
digit plethysmography and pressure cuff size for the toe
width 1.2 times that of the toe 2.5 - 3.0 cm applied to big toe
primary raynauds is more common in _____ and is ______ and ______
women bilateral hereditary
popliteal artery entrapment syndrome is more common in who
young men
fibromuscular dysplasia is most commonly seen in
young women
paper speed =
25 mm/sec
> 400 cm/sec PSV =
> 75% diameter reduction
Normal penile/brachial index
>0.75
bruit
a noise heard as the result of turbulent flow
most common cause of an IVC tumor
renal cell carcinoma
most common solid renal mass in an adult
renal cell carcinoma
angioplasty is most commonly performed on which arteries
renal, iliac, femoral, popliteal artery
mechanism for hypertension
renin
abnormal venous signals require ________ and _________ before a conclusion can be made
repositioning re-evaluation
how to correctly identify a vein with CW
requires hearing accompanying arterial signal
AC coupling stands for
alternating current
incompetence veins can also lead to increasing pressure when patient stands or walks
ambulatory hypertension
posterior tibial artery extends down ______ of the leg
posterior/medial side
Ulcer appearance
deep and more regular painful compared to venous ulcers
hydrostaic pressure gradually increases from level to level down the body reaching
100 mmHg at the ankle
normal PSV in the SMA
110-177 cm/sec
GSV has how many valves?
12 most below knee
for UE doppler pressure test what size is the cuff on the upper arm
12 x 40 cm
an acceleration time of less then ______ suggests presence of proximal iliac disease
133 msec
Nyquist limit
1/2 PRF
Largest intra-arterial connection?
Circle of Willis
homonymous hemianopsia
Defective vision or blindness affecting the right or left halves of the visual fields
renal veins empty into
IVC
considered resistance vessels
arterioles
atheromatous plaque is a form of
arteriosclerosis
paried posterior tibial veins empty
back of leg
best way to image intra caval device
flouroscopy
subclavian artery course
laterally to the outer border of the first rib
pneumatic
pertaining to air or gas
methods to identify reflux
spectral analysis and color flow imaging
dissecting aneurysm often occurs in
thoracic aorta
Specificity calculation
# of true negative test/ # of all negative diagnoses detected by the gold standard
negative predictive value calculation
# of true negative tests/ # of all negative noninvasive studies (true negatives + false negatives)
sensitivity calculation
# of true positive test/ # of all positive diagnoses detected by the gold standard
another term for ABI is
API (ankle/arm pressure index)
Heparin
Anticoagulant
vasopspam most often occurs where in the circle of willis
MCA
what types of methods for a volume plethysmography exam?
3 or 4 cuff method
begin CW exam with ______ side
asymptomatic
aneurysm is rarely seen in
cervical carotid artery
arterial system is set into oscillation by
each beat of the heart
toe pressures of <30 mmHg are evident in foot or tow ulcers that
failed to heal
when disteneded the cross sectional area of the vein is ______ times that of the corresponding artery
3-4
interpreting transcutaneous oximetry TcP02- borderline healing values occur with a p02 of
30 - 40 mmHg
symptoms frequently seen with PCA lesion
-dyslexia -coma -paralysis usually does not occur
size of cuff on thigh can be
19 x 40 cm
The ECA originates from the ___
CCA
high transmural pressure
High volume results in circular shape
systemic venous hypertension leads to
persistant dilated vessels evident
maximum frequency is represented as
1/2 PRF (nyquist limit)
hemodynamically significant stenosis for arteriography
50% diameter reduction
normal PSV in the celiac artery
50-160 cm/sec
small saphenous has how many valves?
6-12 valves
PPG can determine changes in
blood content of skin (microcirculation) which reflects intravenous volume
aneurysm
dilation of an artery; usually due to a weakness or degeneration in the wall of the artery
DC coupling stands for
direct current
color doppler phase
direction
helical flow
flow moves into a wider portion of the vessel (carotid bulb)
chronic changes of a vein color flow doppler will appear
flow will change from away from the probe to towards the probe in venous reflux
pitting edema
fluid in subcutaneous tissue
two types of electrical coupling
DC and AC
when performing venous plethysmography make sure which settings are on
DC and PPG
Internal friction within a fluid is measured how?
It's measured by its Viscosity
Low transmural pressure
Low volume of blood results in dumbbell shape
Doppler flow distal to a significant stenosis is
Lower resistant. In addition it's more rounded in appearance and is weaker in strength (tardus parvus)
calculating stenosis is based off of
NASCET study North America Symptomatic Carotid Endarterectomy Trial
Pseudoaneurysm
Results from a defect in main artery wall a channel communication from main artery to pulsatile structure outside vessel walls.
The Right CCA is a branch of the?
Right Innominate
Reversed Saphenous Vein Graft (RSVG)
Small end is now prox Large end is distal Vein valves stay open due to arterial flow pressure Branches are litigated (GSV becomes artery, carries blood around blockage)
Veins without valves
Soleal sinuses Internal iliac Common iliac Inferior and superior vena cava Subclavian Innominate External iliac veins contains valves 25% of the time.
angioplasty is imaged under
fluoroscopy
normal venous ejection fraction want this number to be a
high %
Leriche syndrome can be diagnosed in males struggling with
impotence
artifacts can occur with volume plethysmography due to
improper cuff application
Reverse Trendelenburg's position
The head of the bed is raised and the foot of the bed is lowered 15-30 degrees
valvular incompetence
The inability of valve to either open or close properly, valve no longer maintains unidirectional flow
Inertia
The tendency of an object to resist a change in motion
velocity formula
V = c x DF / 2 x Fo x Co sine
diabetic patients have an increased risk of developing
gangrenous changes or amputations
positive predictive value calculation
# of true positive tests/ # of all positive noninvasive studies (true positives + false positives)
poiseuilles law defines a relationship between
(P) pressure, (Q) volume flow, (R) resistance
two reasons for peroperative arterial mapping of the internal mammary artery
-recipient site for free flaps in breast reconstruction -graft to the left anterior descending (LAD) coronary artery
what is the hydrostatic pressure at the heart
0
what is the hydrostatic pressure exerted on veins and arteries in the supine position
0
grading pulses on a scale of
0 (none) - 4 (bounding)
minimum measured pressure is
0 mmHg
in a supine patient the HP against the veins and arteries at the ankle is
0 mmHg (ankle p = circulatory p + 0 mmHg)
ABI with claudication (moderate disease)
0.5-0.8
Marginal penile/brachial index
0.65-0.74
ABI with mild arterial disease
0.8-0.9
normal finger/brachial indices (used in digit plethysmography and pressures)
0.8-0.9
CFV has how many valves?
1
jugular vein has how many valves?
1
sample size used for obtaining pulse doppler imaging in the UE arteries
1 - 1.5mm size increased if needed
location of the SMA
1 cm below/behind the celiac artery
if you must repeat a pressure measurement the cuff needs to be fully deflated for ________ prior to repeat inflation
1 minute
once patient is standing air plethy somography exam is record when the patients weight is distributed equally over both feet and patient begins to perform
1 tip toe exercise to document a decrease in calf VV (venous volume) (documented as ejection volume EV) and the venous filling time (VFT) 10 tip toe maneuvers completed
after _______ minutes post injection of the penis the _______ measurements are obtained
1-2 A/P of cavernous arteries, PSV and EDV, dorsal vein velocities
femoral contains how many valves?
1-3 valves
popliteal contains how many valves?
1-3 valves
general considerations for interpretation of exams
1. include clinical indications for the exam 2. adequate description of the exam performed 3. description of positive as well as negative findings 4. characterization of disease 5. reasons for a technically limited or incomplete exam 6. comparison with previous studies if applicable 7. identification of the technologists who performed study
normal length of the kidney varies from __________ depending on patients size
10 - 12 cm
interpreting transcutaneous oximetry TcP02- non-healing (poor values) occur with a p02 of
10 - 15 mmHg
during volume plethysmography a measurement amount of air is inflated into a cuff to pressure ranging from
10 to 65 mmHg depending on cuff size
for UE doppler pressure text what size is the cuff on the forearm
10 x 40 cm
in a standing patient the HP against the veins and arteries at the ankle is
100 mmHg (ankle p = circulatory p + 100 mmHg)
typical size of cuffs with exception to the thigh cuff which usually contains a longer cuff bladder
12 x 40 cm
to finally obtain a p02 reading for trasncutaneous oximetry TcP02 after manual calibration it takes about ________ minutes
15-20
a ________ difference from one brachial pressure to the other suggests ________ stenosis of the subclavian artery and/or vessel under the cuff
15-20 mmHg >50%
normal limbs with reactive hyperemia test will show a transient drop of
17-34%
when ABI pressure drops after exercise pressures are re taken every ______ minutes until _______ are attained
2 pre exercise pressure
what transducer is used for TCD exam
2 MHz pulsed doppler
Continous Wave Doppler
2 crystals in transducer one constantly transmitting one constantly recieving
the number 2 in the doppler shift represents
2 doppler shifts
how many vessels have to be abnormal to be consistent with chronic mesenteric ischemia
2 of 3 (SMA, IMA, Celiac)
acceptable vein diameter measurement should be atleast
2-3 mm
_______ of patients requiring PTLA have complications requiring surgery or hospital stay
2-3%
cuff size to maintain non imaging penile pressue
2.5 x 12.5 cm
The width of the cuff for the doppler of LE should be _____% the circumference of the leg
20
pressure cuffs in the legs should be inflated ______ beyond last audible doppler arterial signal
20-30 mmHg
after the exam is is crucial the patient monitor his erection and if it exceeds more then ______ hours a urologist needs to be contacted immediatley to reverse the priapism
3
posteior arch vein has _______ ankle perforators
3
a decreae ______ in any graft segment is considered abnormal
30cm/sec
in a normal doppler imaging study of the penis the PSV should increase _______ or higher post injection
30cm/sec
gold standard sensitivity
TP/ TP + FN
50-79% stenosis - PSV and EDV
PSV >125 cm/sec EDV <140 cm/sec
80-99% stenosis - PSV and EDV
PSV >125 cm/sec EDV >140 cm/sec
evaluation of a bypass graft in the LE is usually combined with
ABI
occluded vessel - PSV and EDV
PSV absent EDV absent
complicated lesion
A fibrous plaque that includes fibrous tissue, more collagen, calcium and cellular debris
Resistivity Index (RI)
PSV-EDV/PSV
calf segmental pressure below the knee compresses which arteries
PTA or DPA (uses the highest pressure)
reasons you can not use the renal aortic ratio
AAA is detected aortic PSV > 90cm/s aortic PSV < 40 cm/s
MRA is useful for finding
AAA, dissections, peripheral artery evaluation
Types of Doppler Velocimetry
Analog and Spectral analysis
arteriosclerosis
abnormal hardening of the walls of an artery or arteries
bruit ausculation
abnormal sound heard from a stethoscope
ankle segmental pressure of the lower leg compresses which arteries
PTA, DPA peroneal artery (only if necessary)
soleal sinus drains blood into the
PTV and peroneal veins
common bypass grafts
AO to both iliac arteries (also used for AAA) Ao to bi-femoral (also used for AAA) Femoral to Pop Femoral to PTA; ATA; peroneal
tibioperoneal trunk short segment between ______ and the branches of ________
ATA PTA and peroneal
popliteal vein is formed by a union of the
ATV and posterior-tibial trunk
most common post stenotic bypass graft complications
AV fistula; valve cusp
fibrous plaque
Accumulation of lipids, collagen and elastic fibers
quantitative evaluation for venous reflux with cuff at foot color doppler and PSV are assessed at the
PTV at TM level evaluated
what makes steady flow easier to deal with
behavior is more predictable
_______ arteries is used to obtain the BP in the forearm
radial and ulna
quantitative evaluation for venous reflux with cuff at calf color doppler and PSV are assessed at the
PV and GSV evaluated seperately
pulmonary embolism (PE)
Blocking of a pulmonary artery due to a blood clot
varicose veins
abnormally swollen, twisted veins with defective valves; most often seen in the legs pooling of veins
reflux is measured
above the baseline in how many seconds until below baseline
Artiography involves placement of a catheter in which arteries
CFA (safest approach), axillary, brachial
second aneurysms typically occur in
CFA or popliteal
Penile Non-Imaging Technique obtains velocity signals bilat of
CFA, PTA, DPA
quantitative evaluation for venous reflux with cuff at thigh color doppler and PSV are assessed at the
CFV and saphenofemoral junction evaluated seperately
reactive hyperemia is used when patients have
PVOD in contralateral leg, use a can or walker, pulmonary problems, poor cardiac status
troubleshooting for plethysmography - no tracing?
check the exam mode, paper and connection points
Late systole/early diastole:
Temporary flow reversal, due to a phase shifted negative pressure gradient and peripheral resistance, causing reflection of the wave proximally
troubleshooting for plethysmography - cant center stylus?
check the mode AC mode for arterial DC mode for venous
the obstructive disease with a segmental pressure differenceof >30 mmHg is located
above the level in the leg with the lower pressure
what is utilized to monitor changes for thoracic outlet syndrome
PPG or doppler waveforms
aliasing results in a low
PRF
leriche syndrome what may the patient experience in the LE
absence of femoral pulse, coldness or pallor
normal vessel appearance in B-mode
absence of wall irregularities or soft tissue abnormalities
_______ ICA doppler signal or ________ thump determines occlusion
absent pre-occlusive
Palpable pulses can be felt where?
aorta, femoral, popliteal, dorsalis pedis, and posterior tibial arteries
stent grafts and most utilized in which vessels
aorta, renal, iliac, femoral, repair of AAA
The Left CCA is a branch off the?
aortic arch
brachial artery becomes the
radial and ulnar arteries at the inner aspect of the elbow (antecubital fossa)
Symptoms frequently seen with MCA lesion
aphasia, dysphasia, severe facial and arm hemiparesis or hemiplegia, behavioral changessympt
digit plethysmography of the fingers without cold stress cuff size
applied to all fingers 2 - 2.5 cm
cephalic vein can be harvested for
arterial bypass conduit
pressure measured in a standing position is
too high
Plethysmography helps detect the absence/presence of
arterial disease
digit plethysmography and pressures helps detect the presence of
arterial disease and assess effects of treatmentlimit
low PSV velocities obtained in an access graft could indicate
arterial inflow problems
what governs the amount of blood that leaves the arterial system?
arterial pressure and peripheral resistance
acute renal transplant rejection often increases
arterial resistance
phlegmasia alba dolens (milk leg)
arterial spasm secondary to extensive acute iliofemoral thrombosis; limb threatening
AC is used for
arterial studies
serves as reservoirs to store some blood volume and potential energy supplied to the system
arteries
similar technique as used in _________ is utilized with insertion of stent introducer sheath
arteriography
Accuracy calculation
total # of correct tests/ total # of all studies
IVC interruption device is usually placed
below renal veins and may appear as bright echogenic lines
in a complete subclavian steal the ispilateral verterbral artery will be located
below the baseline
to calculate the velocity _________ must be known
DF
diameter reduction =
DR= (1-(d/D)) x 100
limitation of CW doppler is it is unable to differentiate abnormal flow patterns from
DVT versus extrinsic compression
Accurate vessel identification for TCD exam requires:
Depth of sample volume, velocity of the blood flow, direction of blood flow and relationship of flow patterns to one another
ulcerative lesion
Deterioration of the normally smooth surface of the fibrous cap; may result in distal embolization
Doppler equation
Df = 2 x Fo x V x Co sine / c Df = Doppler shift frequency Fo = Carrier frequency V = Velocity of the moving reflectors c = speed of ultrasound through tissue (1540m/sec) co sine = angle
risk factors for arterial disease
Diabetes, Hypertension, Hyperlipidemia, Smoking, Other-not controllable: age, family history
What has the most dramatic effect on resistance?
Diameter change
cross sectional area reduction of 75% =
Diameter reduction of 50%
How is ABI calculated?
Divide the highest ankle systolic pressure with the highest brachial pressure for the index
arteries with high resistance flow
ECA, subclavian, aorta, iliac, extremity arteries, fasting SMA
Important anastomoses include:
ECA-ICA connections via orbital and opthalmic arteries occipital branch of ECA with atlantic branch of vertebral deep cervical and ascending cervical branches of subclavian to branches of lower vertebral artery
transplant RA anastomosed to
EIA or IIA
transplant RV anastomosed to
EIV
End diastolic Ratio =
End Diastolic V / PSV
majority of blood flows into what branch of the cca
ICA
most common place for occlusion in the circle of willis
ICA or MCA
low resistance flow example arteries
ICA, vertebral, renal, celiac, splenic, hepatic
what can make CT more discrete?
IV contrast
phasic, bi-directional/ pulsatile doppler signals in
IVC, renal vein, hepatic vein
Raynaud's phenomenon
Intermittent digital ischemia in response to cold or emotional stress
neointimal hyperplasia
Intimal thickening from rapid production of smooth muscle cells
what arteries can be imaged in a unilateral transtemporal approach
MCA, ACA, PCA, terminal ICA
Symptoms frequently seen with ACA lesion
More severe leg hemiparesis or hemiplegia Incontinence Loss of coordination
food challenge test post prandial the _______ and _______ of the SMA are obtained
PSV EDV
less than 50% stenosis - PSV and EDV
PSV <125 cm/sec EDV N/A
normal % of stenosis - PSV and EDV
PSV <125 cm/sec EDV N/A
embolism
Obstruction of a blood vessel by a clot of blood or foreign substance
vena caval interruption device placed to prevent
PE in patients who cant be anticoagulated
usual method for obtaining great toe pressure
PPG
how to perform exam for thoracic outlet syndrome
PPG attached to index finger or CW doppler on radial artery resting waveform obtained and waveforms in various arm positions while obtaining arterial pulsations
how to document the results of the allen test
PPG on the index finger to document arterial pulsations before and after a clenched fist
Valsalva maneuver
Patient takes in deep breath and holds in breath while bearing down as if trying to move the bowels.
PPG
Photoplethysmography - reflects the blood movement in the vessel which goes from the heart to the finger tips
Poiseuille's equation
Q = (p1 - p2) pie x r^4 / 8 v L p= pressure at prox and distal ends
the law of conversation of mass formula
Q = A x V
Pousille's law combined with resistance equation
Q = P x pie x r^4 / 8 n L Q= quantity of flow p= pressure gradiant across arterial segment r= radius of vessel n= viscosity of fluid L= length of vessel
Resistance formula
R= 8vL / pie x r^4
how is energy lost in the form of heat
RBC layers rub against each other
coronary arteries supply blood to the
Right coronary artery supplies blood to the right atrium and right ventricle Left coronary artery supplies blood to the left atrium and left ventricle
most frequent complication of aneurysm
Rupture of AO aneurysm, embolization of peripheral aneurysms Note: both types can accumulate thrombus inside
adductor hiatus acts as a termination of the _____ and the beginning of the ______
SFA and popliteal artery
If IMA is easily seen observe for proximal stenosis of _______ or ________
SMA celiac
mesenteric angina may be due to a stenosis or occlusion of what arteries
SMA, celiac, IMA
surgical procedure of varicose veins
SSV removed or phlebectomy
Endoleak
Seepage of blood back into old aneurysm outside the graft
Virchow's triad
Stasis, hypercoagulability, endothelial damage
Steady flow originates from a
Steady driving pressure
Time averaged maximum velocity (TAMV) or mean velocity used with
TCD exam Not PSV and EDV
gold standard specificity
TN/ FP + TN
gold standard acurracygoo
TP + TN/ TP + FP + FN + TN
sum of pressure (potential), kinetic and gravitational energies
total energy contained in moving fluids
when evaluating for deterioration observe
deterioration from one signal to the next as well as deterioration from a previous study
palpable vibration or thrill over pulse site may indicate
fistula, post stenotic turbulence, patent dialysis access site
during volume plethysmography diastole appears as
fixed amount of air pressure in cuff small artery
Bernoulli's Principle
total fluid energy along a streamline of fluid flow is constant
digit plethysmography and pressures can differentiate between
fixed arterial obstruction and vasospasm
pre- prandial of the SMA PSV? EDV? flow reversal?
high low yes
If no augmentation with distal compression is seen, think about an obstruction where?
between where you are compressing and where you are listening or slightly more proximal
four cuff and three cuff method are both
bilateral
normal flow seen in a bypass graft is
low resistant
Atherosclerosis
The build-up of fats, cholesterol, and other substances in and on the artery walls.
renal arteries, kidney arteries, celiac, splenic, hepatic arteries normally have what kind of flow
low resistant
some limitations of the stent graft depending on location
abdominal gas inability of patient to lie flat complications similar to those of arteriography
portal vein drains
abdominal part of digestive tract, pancreas, spleen, gallbladder
Sesitivity
ability of a test to detect disease
residual volume fraction (RVF) is calculated as
VV remaining after 10 tip toe movements
how do you get the negative circulatory pressure when body part is raised above heart?
Vessels will collapse at 0 mmHg if the arm is raised above the head that is how you get the negative number
if faulty valve seen its treated with
ablation if in superficial system
reduced PSV in smallest graft diameter then it previously was is considered
abnormal
with popliteal entrapment syndrome diminished flow to the great toe is considered
abnormal
Steal syndrome occurs when
a fistula or graft "steals" too much blood away from the distal part of the limb.
what happens to extremity arteries after virgorous exercise
low resistant monophasic vasodilation
venous outflow of the AVF
low resistant more pulsatile
p02 means
partial pressure oxygen
organic (fixed) obstructive disease contain _______ doppler arterial signals _________ systolic pressures and _________ PPG tracings (plethysmography)
abnormal abnormal abnormal
________ flow not seen or not present can underestimate disease
accelerated
may expect some flow ______ post-stenting
acceleration
may expect some flow _________ post stenting
acceleration
analog has a acceptable
accuracy
troubleshooting- recording stylus stuck at a lower or upper portion of tracing?
acitivate reset control to re center
hyperechoic very bright/ highly reflective echoes, acoustic shadowing from calcium deposit
acoustic shadow from calcium deposit may result in erroneous calculation of % stenosis
troubleshooting for plethysmography - stylus wandering on paper?
activate the reset control and be sure correct exam function is selected
ascending venography is used for evaluation of
acute DVT, congenital venous disease, evaluation of chronic venous thrombosis
venous photo plethysmography is contraindicatedon
acute deep vein thrombosis
adductor hiatus also called
adductor canal or hunters canal
how to maximize color filling in a venous exam
adjust color scale to detect slower velocities change filters increase color gain
troubleshooting- venous plethysmography- deflections off the scale of barely discernible?
adjust gain/sensitivity/ size setting
factors that may alter intracranial blood flow for TCD exam
age, sex, hematocrit, blood gases, metabolism
howis volume plethysmography recorded
air is inflated in the cuff beginning with the upper part of the extremity and moving distally and you need to record atleast 3 pulses
contraindications of thrombin injection for a pseudo aneurysm (PSA)
allergy to thrombin or bovine materials infection in groin ischemia of overlying skin distal limb ischemia very short or wide neck
with the food challenge test what do you need to document
amount of high caloric liquid ingested (1-2 cans) onset, type and duration of symptoms time began post prandial study
other findings evident with arteriography
aneurysm vasospasm- severe narrowing without occlusion fibromuscular dysplasia- multiple arterial stenosis caused by medial hyperplasia appears as string of beads
repeated trauma to the popliteal artery can result in
aneurysm, thrombosis, emboli
co sine =
angle determined by the image
Angle the probe so blood flow moves ___ (toward the probe).
antegrade
what kind of flow in ACA
antegrade
popliteal artery branches at the interval between the tibia and fibula into the
anterior and posterior tibial arteries
anterior cerebral arteries are joined together by the
anterior communicating artery
The first branch of the distal popliteal artery is the
anterior tibial artery
trifurcation in the lower extremity refers to
anterior tibial artery, posterior tibial artery and peroneal artery
flow direction in the circle of willis is from
anterior to posterior
vessels followed from clavicle to mandible use what views
anterior, oblique, lateral, posterior oblique
how does the supraorbital artery travel
anterioraly and superiorly to the globe
_________ approach to help evaluate ATV
antero-lateral
pharmacologic treatments for contrast venography
anticoagulant therapy lytic therapy
preopperative arterial mapping of the radial artery how do you decide if the radial artery is efficient for coronary artery bypass?
assess patency of the palmer arch with a modified allen test, the patient does not make a fist but uses the PPG to monitor various digit pulses with and without radial compression plethysmography pulsations should continue during radial artery compression if pulsations disappear there is no need to proceed because removal of the radial artery will compromise the hand
techniques plethysmography uses to help localize the level of obstruction
assessment of follow of treatment PPG mianly used for evaluation of digits and penile vessels
25-30% of population with thoracic outlet syndrome has
asymptomatic compression
with the 4 cuff technique the normal AK and BK pressure is
at least the same as the highest brachial pressure
the fastest moving flow within laminar flow is
at the center
with laminar flow lower frequencies are distributed where?
at the walls (boundary layer)
subclavian artery becomes the
axillary artery
paget schroetter syndrome usually involves what veins
axillary or subclavian
what can cause neointimal hyperplasia
denuding (strip of) of the endothelium leads to platelet accumulation, endothelium regeneration and smooth muscle cell proliferation
IVC and iliac vessels are non-compressible due to
depth of the vessel
superficial veins of the upper extremities
basilic and cephalic
_______ is often larger then the cephalic vein
basilic vein
fribromuscular dysplasia has what kind of appearance on angiography
bead-like
main disadvantage of pulse doppler
because machine has a waiting time to listen for a return there is a limit to how fast it can measure velocity
good hand washing technique requires hand washing
before/ after direct patient contact after handling bodily fluid after using bathroom
small sphenous vein ascends
back of calf joining at the popliteal vein
if waveform is spontaneous without augmentation
bad
duplex/color imaging LE arteries can be used to localize the stenotic lesion prior to
balloon angioplasty
other limitations of digit plethysography that involve contact of cuff or photocell
bandages that can't be removed, ulcerations or gangrene, tremor
anyone providing direct patient care are trained in
basic cardiac life support
which artery is formed by the confluence of vertebral arteries
basilar artery
how does the internal mammary artery travel?
descends on the posterior side of cartilage of upper 6 ribs about 1 cm from sternum
troubleshooting- recorder stylus not recording Fix?
check that proper test selection and/or probe type has been made
in order to get a good doppler pressure reading in the leg complete _______ of blood flow is required
cessation
Proximal to a stenosis the waveform is
dampened with or without disturbance
Gangreene
death of body tissues, usually from loss of blood supply
exhalation in the venous system causes _________ in intra-abdominal pressure and _________ in blood flow from lower extremities
decrease increase
inspiration in the venous system causes a _________ in intra-thoracic pressure and ___________ in blood flow from UE
decrease increase
effective calf muscle pump venous volume and pressure ________ and venous flow to the heart ___________
decrease increases
methods of increasing the PRF/ nyquist limit
decrease baseline increase doppler scale change transducer frequency alter angle of insonation decrease depth use CW doppler
troubleshooting- 60 cycle noise tracing?
decrease gain; turn system off/on; increase filter; try another plug receptable
how to control risk factors related to virchows triad
decrease venous stasis prevent injury or infection aware of hypercoagulability states/factorsphar
atherosclerosis can result in _________ perfusion to the brain
decreased
in vasodilation pulsatile changes in medium/small sized arteries of the limbs are _______, pulsatility changes are ________ in the minute arteries
decreased increased
an increase in capillary re fill time denotes
decreased arterial perfusion
abnormal ABI post exercise will be
decreased minimally or to a severe amount
The reversal component of a high resistant signal may disappear distal to a stenosis because of
decreased peripheral resistance secondary to ischemia
upper extremities _______ with expiration and ________ with inspiration
decreases increases
the high velocities consistent with median arcuate ligament syndrome is improved with
deep inspiration
ulnar artery branches into
deep palmer branch and terminates in to the superficial palmer arch
plantar arch consists of _______ and ______
deep plantar artery (branch of DPA) and lateral plantar artery (branch of PTA which unites with the deep plantar)
venous photoplethysmography shows VRT < 20 seconds with or without tourniquet application is an example of
deep system incompetence
Kippel-Trenaunay Syndrome can include hypoplastic or absent
deep veins
Continuous Wave Doppler evaluates
deep venous obstruction venous incompetence
arterial ulcers appearance
deep, regular shape "punched out" appearance
a phased array transducer is used for imaging
deeper structures of the abdomenduplex/color
pallor skin results in
deficient blood supply, pale skin
tissue loss due to chronic occlusive disease is due to
deficient or absent blood supply
patient positioning to image LE peripheral veins
facilitate venous filling- reverse trendelenburg dminish extrinsic compression- extreme lateral decubitis reflux testing- patient is standing, bears weight on contralateral leg
Contraindications
factors that prevent the use of a drug or treatment opposite of indication
volume and photo plethysmography normal waveform appears as
fairly rapid upslope, sharp, systolic peak with reflected wave
Drop attack
falling to the ground without loss of consciousness
incompressible vessels with LE doppler segmental pressures have _________ and ________
falsely elevated inaccurate pressures
LE doppler pressures artifacts caused by the cuff; if the cuff is too large for a limb segment BP will _________; if the cuff is too narrow for a limb segment BP will __________
falsely lower falsely higher
treatment for anterior compartment syndrome
fasciotomy
AC detects
fast changes in blood content
spectral analysis utilizes __________ method
fast fourier transform (FTT)
abdominal vessels are imaged on a ________ patient
fasting
Types of atheromatous plaque
fatty streak. fibrous plaque. complicated lesion. ulcerative lesion. intra-plaque hemorrhage.
hypoechoic or homogenous low level echoes found withinin lumen
fatty streaks
retrograde flow with augmentation results
faulty valve (venous insufficiency)
common femoral vein formed by joining
femoral vein and deep femoral vein
an example of outflow disease
femoral-popliteal disease
easy place to find the peroneal veins
few centimeters proximal to the maleolus; deeper then PTV
most commonly caused by dysplasia of media along with overgrowth of collagen mid/distal ICA
fibromuscular dysplasia
homogeneous medium to low level echoes within a vessel lumen
fibrous plaque
reason veins have valves
fighting gravity
CW doppler the spectral window is
filled in
how to disinfect external ultrasound probes
first, remove visible residue with a soft cloth lightly dampened with mild soap isopropyl alcohol solution used- dont let it air dry
purpose of the heart pumping
generate pressure to move blood
another name for collaterals in the popliteal artery
genicular branches
pressure gradiants (flow seperation) occur because of a
geometry change due to curves of the vessel or intr-luminal disease
pressure gradiants or areas of flow seperation can occur in a vessel because of
geometry change with or without intraluminal disease
types of high level disinfectant
gluteraldehyde- cidex hydrogen peroxide > 6 %
contrast venography is considered to be the
gold standard
color/duplex imaging of UE arterieslimitations pertaining to hemodialysis access grafts
graft angulation difficult to adequately evaluate outflow of vein in obese patient
equivalent to the weight of the column of blood extending from the heart to level where pressure is measured (standing patient)
gravitational energy (hydrostatic pressure HP)
Vein bypass graft evaluation includes:
gray scale color flow imaging PSV
3 essential image for lower extremity exam
gray scale - observe for plaque color- flow patterns doppler- PSV
Synthetic bypass graft evaluation includes:
gray scale, color image, PSV
superficial veins of the lower extremity
great saphenous vein and small saphenous vein
once vein is completely distended _________ changes required to accommodate further increase volume
greater pressure changes
longest vein in the body originating at the dorsum of foot
greater saphenous vein
strandness criteria
greater then 50% stenosis as a peak systolic velocity
patients with one aneurysm has a higher incident of
having a second one
superior vena cava drains
head and upper extremity veins
another altrnative way to prove relfux with distal aug is to position patient
head up higher then legs to force reflux
inraoperative monitoring of the circle of willis technique
headset is utilized for continuous monitoring not working in sterile field
pressure is greater at the ______ and gradually decreases as blood moves ______
heart farther away
stethoscope can be used to exam what vessels
heart, carotid, aorta, femoral, popliteal arteries
as blood moves farther out to the periphery energy is dissipated largely in the form of
heat
Venous Plethysmography exam stylus records on
heat sensitive paper
displacement plethysmography is measured by
height of the water in the chimney, volume changed by the spirometer
capabilities of arterial doppler waveform
help confirm diagnosis/approximate location of arterial occlusive disease indicate severity of the occlusive process
duplex/color flow UE arteries imaging used to evaluate what post-op?
hemodialysis access arterial bypass graft
clinical findings of budd-chiari syndrome
heptomegaly, abdominal pain, sudden onset of ascites
circle of willis resembles what shape
hexagon
3 cuff method uses one large cuff thats placed ______ on the thigh
high
pre- prandial of the celiac artery PSV? EDV? flow reversal?
high high no
AVF is a abnormal connection of _____ pressure arterial system and _____ pressure venous system
high low
Flow through the AVF has ______ velocities and ________ resistant flow
high low
Extravasation
leakage of IV infused and potentially damaging medications into the extravascular tissue around the site of infusion
left renal vein is a landmark for identifying
left renal artery
landmark for locating the left renal artery
left renal vein runs anterior to the aorta and posterior to the SMA the renal artery will be just posterior to the left renal vein
blood flow to and from the heart
left ventricle, aorta, large arteries, arterioles, capillaries, venules, large veins, vena cava, right atrium
Resistance is directly proportional to
length of vessel and viscosity of blood
Effects of flow abnormality produced by a stenosis depends on factors such as:
length, diameter, shape, degree of narrowing pressure gradiant, peripheral resistance beyond stenosispro
Plethysmography can help localize the _______ obstruction
level of
confluence of the iliac veins into the IVC is located at the
level of the 5th lumbar vertebra
treatment for CBT
ligation of feeding vessel which is usually the ECA
photocell consists of
light emiting diode and photo sensor
with photo plethysmography photocell consists of
light emitting diode and photo-sensor
how to decrease venous stasis in order to help treat contrast venography
limit long periods of inactivity or bed rest promote venous drainage by elevating leg, intermittent pneumatic calf compression during and after surgery, wear support hose or elastic stockings
hepatic vein carries blood from
liver into the IVC
where do the renal tranplant kidneys come from?
living-related or cadaveric donor kidneys
saccular aneurysm
localized out pouching
if hemodialysis access site is present identify
location, extent, type, aneurysmal changes, puncture sites, peri-graft fluid, thrombus
proximal release augmentation takes
longer then distal augmentation
duplex/color imaging of the abdomen uses
longitudinal, transverse, gray scale, color flow patterns, doppler for PSV and EDV
protocol for UE arerty doppler/duplex imaging
longitudinal/transverse to evaluate for thrombus or stenosis in gray-scale doppler PSV obtained stills and vidoes taken as needed
loss of spectral window represents
loss of laminar flow
Normal venous filling time you want number to be
low
collaterals will have _____ resistance
low
morbidity, morality, cost of angioplpasty is
low
the reason you dont obtain doppler segmental pressure from starting high in the leg and move distally is the BP would be
low
normal venous residual volume fraction with this to be a
low %
ptophylaxis coagulation
low dose heparin- interferes with formation of the blood clot and does not lyse (degenerate) an existing thrombus
flow of a continuous (steady) nature feeding a dilated vascular bed
low resistance flow
ICA distributes blood into ___________ vascular beds
low resistant
kidney arteries have what kind of flow
low resistant
intraoperative monitoring of a bypass graft is used to monitor
patency of anastomosis, suspicious stenotic or turbulent areas
factors that can limit the ability to perform arteriography
patient allergic to contrast agent patient in kidney failure inability to provide multiple images in many planes in real time
4 block claudication means
patient complains of pain after walking 4 blocks
patient positioning of carotid artery
patient in comfortable supine position, neck slightly hyperextended, and head turned slightly
patient effects on CT imaging
patient motion and presence of surgical clips
subclavian vein can be followed to the
outer border of the first rib (clavicle prevents further visualization
_______ to _________ diameter mesurements obtained along venous extremity for preopperative vein mapping
outer edge to outer edge
MR angiography is extremely sensitive to the presence of stenosis but tends to
overestimate the disease process
for hospitalized patients make sure equipment is handled with special care such as
oxygen tanks, IV medications
examples of endothelial damage to the vessel
paget-schroetter syndomre PICC line
claudication
pain in muscles usually occuring during exercise
Symptoms of thoracic outlet syndrome
pain, aching of shoulder or forearm, numbness, tingling, or weakness and fatigue in upper limb, exercise, upward positions increase discomfort
digital arteries arise from the
palmer arches and extend into the fingers dividing into lateral and medial branches
peroneal artery are not
palpable
types of inertial losses
parabolic flow pattern becomes flattened flow moves in a disorganized fashion
End Diastolic Ratio (EDR) also called
parenchymal resistance ratio (PR)
several _________ exist to produce color duplex
processing methof
Why is treadmill testing the preferred method for exercise testing?
produces a physiological stress that reproduces a patients ischemic symptoms
purpose of reactive hyperemia
produces ischemia and vasodilation distal to the occluding cuffs
DF is _______ to velocity
proportional
Diminished CCA velocities unilaterally represent
prox disease (inniminate or CCA)
when assesing the radial artery for preopperative arterial mapping the readial artery should be measured
prox, mid, distal
Abnormal waveforms always reflect hemodynamically significant disease ________ to the level of the tracing
proximal
If flow is not phasic but rather continuous, a _________ should be considered
proximal
Peripheral dilation occurs in response to _____art obstruction
proximal
claudication due to chronic occlusive disease usually occurs ______ to the location of symptoms
proximal
thrombosis usually occurs at the most _______ portion of the PICC line
proximal
veins and arteries located close to the heart are considered
proximal
vasodilation of the distal vessels often occur with ________ obstruction which causes _______ in pulsatility and signals to have a ________ flow
proximal reducing low resistant
AVF may involve ______ and ______ arteries/veins as well as _________ arteries/veins
proximal and distal collateral
reduced penile pressure is highly suggestive of
proximal arterial disease aorta-iliac or internal iliac
where are the measurements obtained for preopperative vein mapping of the cephalic and basilic veins
proximal bicep, above elbow, elbow, prox, mid, distal of the forearm, wrist
a compressible vessel with evidence of rouleau formation on B-mode could be normal or suggestive of
proximal obstruction
it is recommended to obtain bilateral blood pressures to detect
proximal obstruction
sources of false negative color flow studies
proximal obstruction technically limited studies
monphasic waveform is often seen where
proximal to an obstruction
when evidence of an abnormal obstructive waveform occurs post finger cold stress test for digit plethysmography where is the occlusion located
proximal to the tip of the finger
what helps expand the vein for preopperative vein mapping
proximal tourniquet (rubber band to stop blood flow)
quantitative forms of spectral analysis
pulatility index (PI) acceleration time
Flow to a cool extremity (vasoconstriction) will have ______ signals
pulsatile
________ changes do not differentiate well between severe stenosis and occlusion
pulsatility
arteriovenous malformations with a TCD exam has very low _______ indices
pulsatility
Energy is continually restored by
pumping action of the heart
complications related to arteriography
puncture site hematoma psuedoaneurysm local arterial occlusion neurological complications
volume and photo plethysmography are evaluated using _______ criteria
qualitative
interpretation of arterial waveform two types
qualitative or quantitative
doppler waveforms pre exercise
qualities are mainted or augmented with no reverse component
________ prevent adequate penetration of infrared light
thickening of skin
atherosclerosis can lead to
thickening, hardening and loss of elasticity of walls
atherosclerosis obliterans changes to the vessel include
thickening, hardening, loss of elasticity of the intima and media artery walls
appropriate size cuffs for quantitative evaluation for venous insufficiency
thigh- 19 x 40 cm or 12 x 40 cm for high thigh calf- 12 x 40 cm foot- 12 x 40 cm
arterial dissection sonographic appearance
thin membrane dividing the arterial lumen into 2 compartments
function of veins
thin walled collapsible tubes that transport blood from capillaries toward heart carry away waste products of cellular activity
other locations for a true aneurysm
thoracic aorta, femoral, popliteal, renal
blood in false lumen of a dissection may
thrombose
post op complications of liver transplant
thrombosis of portal vein, IVC, hepatic artery leading to hepatic infarction
acute arterial occlusion results from
thrombus, embolism or trauma
ulcerations usually located
tibial area, foot, toes
arterial ulcers are typically located
tibial area, toes, bony prominences
arteritis mainly affects which arteries
tibial, peroneal, small distal arterioles and nutrient vessels
paired peroneal veins form common trunk and carry blood cephalad into
tibial-peroneal trunk
paired veins form common trunk and carry blood cephalad into
tibial-peroneal trunk
Although an absent signal may suggest occlusion, it cannot rule out
tight stenosis (string sign)
bruit may not be evident with a very
tight stenosis >90%
if patient is unable to stand what is an alternative
tilt-table may be used
documenting venous photoplethysmography X-axis = and y-axis =
time volume change
on venous photoplethysmography display ________ pulsations usually evident on superimposed tracing of venous flow
tiny arterial
with PPG blood attenuates light in proportion to its content in
tissue
reason to evaluate renal artery with duplex/color imaging
to document > 60% diameter reduction
coaptation is a latin word that means
to fit together
Ankle pressures cannot always be relied upon, such as in diabetic patients, ___ pressures are more reliable
toe
to evaluate pressure for foot ulcer healing use ______ pressure
toe
blue toe syndrome
toe ischemia resulting from embolism of the small vessels improves on its own
presence of high ankle pressures from arterial calcinosis usually negates a
toe/ankle pressure index